PB01 Biliary: Cholangiocarcinoma (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PB01-02 Our Surgical Experiences with Klatskin Tumor: Toward Optimal Care for Advanced Cases
Adianto Nugroho, Indonesia

A. Nugroho, I. Jamtani, R. Saunar, A. Widarso, T. Poniman
HPB Unit, Digestive Surgery, Fatmawati Central General Hospital, Jakarta, Indonesia

Introduction: Surgical resection represents the only potentially curative treatment for Klatskin tumor. Because of the aggressive nature and the absence of effective adjuvant therapy treatment remains still a challenge, especially in centers with minimal multimodal resources.
Methods: Retrospective analysis of 10 patients diagnosed with Klatskin tumor, underwent surgical management in Fatmawati Central General Hospital from 2017 - 2018.
Results: From 10 cases of Klatskin tumor, there were 3 male and 7 female, with median age of 60 (range: 37-73) years old. Imaging diagnosis was done with either CT scan or MRCP due to the limitation from insurance policy. Preoperative staging with Bismuth-Chorlette classification reveal four cases of type II, 3 cases of type III, 2 cases of type IV and 1 cases of type I tumor. Almost all of our cases came late to the hospital, with severe jaundice and comorbidities including severe malnutrition and pneumonia. Surgical resection was attempted in 6 cases, including 4 bile-duct resection, and 2 liver-bile duct resection. Longmire procedure was done for 2 patient, while the other 2 patients receive PTBD and laparoscopic diagnostic, respectively.
Conclusions: In our daily practice, sometimes surgery remains the only choice we can offer to patients with Klatskin tumor, which often came late in their disease process. Every efforts, including resection or bypass procedure, are hope to increase patients chance of survival, and most importantly, their hope towards a better life.
Keywords: Klatskin tumor, bile duct resection, liver resection, Longmire's procedure
PB01-05 Neoadjuvant Chemoradiotherapy before Resection of Peri-Hilar Cholangiocarcinoma (PH-CCA): The Current World Experience
Harry VM Spiers, United Kingdom

M. Baltatzis1, H.V. Spiers2, S. Jegatheeswaran1, A. Siriwardena1,3
1Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, United Kingdom, 2Regional Hepato-Pancreato-Biliary Unit, Addenbrooke’s Hospital, Cambridge, United Kingdom, 3Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom

Background: Treatment with neoadjuvant chemoradiotherapy followed by liver transplantation yields promising results in peri-hilar cholangiocarcinoma (PH-CCA). It has not been established whether neoadjuvant chemoradiotherapy may similarly influence outcome of resection of PH-CCA.
Methods: A systematic review of the literature for reports of patients undergoing resection of PH-CCA after neoadjuvant chemoradiotherapy was performed using Medline and Embase databases for the period between 1990 and 2019. The keywords and MESH headings “hilar cholangiocarcinoma”, “Klatskin”. “chemoradiotherapy” and “chemotherapy” were used. Data were extracted on demographic profile, disease staging, chemoradiotherapy protocols, complications and outcome. Risk of bias was assessed using Cochrane methodology. Seven reports provide the study population.
Results: The median (range) recruitment period was 14 (4 - 31) years. The total number of patients in these studies is 87. Interval from completion of neoadjuvant treatment to surgery varied from 3 days to 6 months. Resection was by hepatectomy with three studies reporting R0 rates of 100%, 24% and 83% respectively. Histopathological evaluation of the resected specimen showed evidence of prior treatment response in the three studies which reported this phenomenon. There were 2 treatment related deaths at 90 days. Median survival was 19 (95% confidence interval 9.9 - 28) months and 5-year survival 18%.
Conclusions: The reports comprising these data are from expert centers but are influenced by selection and reporting bias. These data show interesting potential beneficial effects of neoadjuvant chemoradiotherapy on both R0 rate and complete response in resected specimen. Scientific equipoise currently exists in relation to neoadjuvant chemoradiotherapy for PH-CCA.
PB01-06 Staging Laparoscopy Is Unnecessary in the Pre-Surgical Work-Up of Patients with Peri-Hilar Cholangiocarcinoma (PH-CCA)
Harry VM Spiers, United Kingdom

H.V. Spiers1, S. Jegatheeswaran2, P. Stathakis2, A. Sheen2,3, S. Jamdar2,3, A. Siriwardena2,3
1Regional Hepato-Pancreato-Biliary Unit, Addenbrooke’s Hospital, Cambridge, United Kingdom, 2Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, Manchester, United Kingdom, 3Faculty of Biology, Medicine and Health, University of Manchester, Manchester, United Kingdom

Introduction: The majority of patients with peri-hilar cholangiocarcinoma (PH-CCA) are not candidates for surgery either because of co-morbidity or locally advanced/metastatic cancer. Staging laparoscopy is advocated to reduce non-therapeutic laparotomy. However, modern high-resolution cross-sectional imaging can effectively identify patients with metastatic disease or bi-lobar vascular involvement. This series reports outcome in patients evaluated for surgery without staging laparoscopy.
Methods: During the 11 year period January 2009 to January 2020, 424 patients underwent hepatectomy by an individual HPB surgeon (AKS) in a regional liver surgery service. 22 underwent hepatectomy for type III or type IV PH-CCA and constitute the study population of this report. Patients undergoing surgery for intra-hepatic cholangiocarcinoma are excluded. Pre-operative preparation included percutaneous trans-hepatic drainage of the future liver remnant followed by cardiopulmonary exercise testing and CT of the abdomen and thorax. Vascular involvement was assessed by pre-operative contrast-enhanced magnetic resonance scan. No patients underwent staging laparoscopy.
Results: 8 (36%) were IIIa, 7 (32%) were IIIb and 7 were type IV. All underwent major hepatectomy with 4 (18%) requiring arterial reconstruction to the new remnant liver. During the study period 1 further patient (1 of 23) underwent non-therapeutic laparotomy (4%) because of nodal involvement in stations 8 and 9. Histology confirmed an R0 resection margin in 15 (68%).
Conclusions: As with other single centre reports this is a highly selected series and care must be exercised when extrapolating from these results. However, the data question the dogma of routine pre-operative staging laparoscopy prior to resection of PH-CCA.
PB01-08 Contemporary Surgical Management of Peri-Hilar Cholangiocarcinoma (PH-CCA)
Harry VM Spiers, United Kingdom

H.V. Spiers1,2, P. Stathakis3,4, S. Jegatheeswaran3, S. Jamdar3, A. Siriwardena3,4
1Department of Surgery, Addenbrooke's Hospital, United Kingdom, 2Department of Physiology, Development and Neuroscience, University of Cambridge, United Kingdom, 3Regional Hepato-Pancreato-Biliary Unit, Manchester Royal Infirmary, United Kingdom, 4Faculty of Biology, Medicine and Health, University of Manchester, United Kingdom

Introduction: Peri-hilar cholangiocarcinoma (PH-CCA) is a rare tumour of the liver hilus. Resection is a major surgical undertaking typically requiring hepatectomy with excision of the extra-hepatic biliary tree. Can this type of surgery be undertaken in regional hepatobiliary centers with worthwhile outcomes?
Methods: During the 11 year period January 2009 to January 2020, 424 patients underwent hepatectomy by an individual HPB surgeon (AKS) in a regional liver surgery service. 22 underwent hepatectomy for type III or type IV PH-CCA and constitute the study population. Patients undergoing surgery for intra-hepatic cholangiocarcinoma are excluded. Pre-operative preparation included percutaneous trans-hepatic drainage of the future liver remnant followed by cardiopulmonary exercise testing and CT of the abdomen and thorax. Vascular involvement was assessed by pre-operative contrast-enhanced magnetic resonance scan. There was no policy of neoadjuvant chemo- or radiotherapy. Resection included segment I and reconstruction of biliary drainage was by Roux hepaticojejunostomy. The study was listed as an audit.
Results: 8 (36%) were IIIa, 7 (32%) were IIIb and 7 were type IV. All underwent major hepatectomy with 4 (18%) requiring arterial reconstruction to the new remnant liver. In-hospital mortality was zero. Adjuvant chemotherapy was utilized in 6 (27%). Median (range) survival was 15 (2-74) months.
Conclusions: This is a highly selected series and care must be exercised when extrapolating from these results. However, the data show that liver resection in the hands of an experienced team is a feasible option in carefully assessed patients with type III and type IV PH-CCA.
PB01-11 Recurrence Factors following Curative-Intent Resection for Intrahepatic Cholangiocarcinoma
Hyeong Min Park, Korea, Republic of

H.M. Park, S.-J. Park, J.-H. Park, S.-S. Han, S.-W. Kim
National Cancer Center, Korea, Republic of

Background: Recurrence of intrahepatic cholangiocarcinoma (ICC) after curative resection is common and the prognosis of recurrent ICC is dismal.
Objective: This study was designed to investigate the risk factors and prognosis after disease recurrence following curative-intent resection for ICC.
Methods: Data of patients undergoing curative resection for ICC in a single institution were identified.
Results: A total of 147 patients were included. With a median follow-up of 21 months, 101 patients (68.7%) experienced ICC recurrence. On multivariate analysis, rim-enhanced or hypovascular mass on late arterial phase of CT image (hazard ratio [HR] 3.893, 95% confidence interval [CI] 1.700-8.915; p = 0.0013 and HR 6.241, 95% CI 2.670-14.586, p < 0.001, respectively), macrovascular invasion (HR 0.518, 95% CI 0.280-0.960; p = 0.037), microvascular invasion (HR 1.813, 95% CI 1.134-2.900, p = 0.013), advanced T stage ( HR 1.801, 95% CI 1.105-2.934, p = 0.018), and Lymph node metastasis (HR 2.067, 95% CI 1.168-3.657, p = 0.013) were associated with recurrence of ICC following curative resection, independently. Median survival after recurrence was better among patients who tried any treatment modality (18.5 months) than patients who did not received treatment (5.0 months) [p < 0.001].
Conclusions: Several factors including preoperative vascularity of ICC on CT image are the independent risk factors for recurrence of ICC after curative resection. Proactive treatment for recurrent ICC can be helpful to prolong the survival length of patients with recurrent ICC.
PB01-12 Recurrence Patterns and Prognosis Following Curative-Intent Resection for Intrahepatic Cholangiocarcinoma
Hyeong Min Park, Korea, Republic of

H.M. Park, S.-J. Park, J.-H. Park, S.-S. Han, S.-W. Kim
National Cancer Center, Korea, Republic of

Background: This study was designed to investigate the patterns, timing, and prognosis of disease recurrence after curative-intent resection for ICC.
Methods: Patients undergoing curative resection for ICC in a single institution were identified. Data on timing and first sites of recurrence, recurrence management, and long-term outcomes after recurrence were analyzed.
Results: A total of 147 patients were included. 101 patients (68.7%) experienced ICC recurrence. In the cohort, 12 patients (11.9%) recurred at the surgical margin, 28 (27.7%) recurred within the liver away from the surgical margin, 41 (40.6%) recurred at extraheptatic sites, and 20 (19.8%) developed both intrahepatic and extrahepatic recurrence. More than 70% (70.3%) of all recurrence occurred within a year after primary surgical resection. Extrahepatic-only recurrence (median 7.8 m) and Both intrahepatic and extrahepatic recurrence (median 5.4 m) tended to occur early, while intrahepatic recurrence at non-margin sites occurred later (median 10.2 m; p = 0.027, and p = 0.003, respectively). Median survival after recurrence was better among patients with intrahepatic recurrence (29.2 months) or extrahepatic recurrence (10.6 months) or locoregional recurrence (21.2 months) was better than patients with both intrahepatic and extrahepatic recurrence (4.4 months) [p < 0.001, p = 0.024, and p = 0.045, respectively].
Conclusions: Different recurrence patterns, timing of recurrence, and prognosis suggest biological heterogeneity of ICC.
PB01-14 Experience of Total Laparoscopic Radical Resection of Hilar Cholangiocarcinoma: Report of 21 Cases
Yusheng Du, China

W. Zhao, Y. Du
Department of Pancreatic Surgery, Affiliated Hospital of Xuzhou Medical University, China

Objective: To investigate the feasibility, safety and clinical effect of total laparoscopic radical resection of hilar cholangiocarcinoma.
: Retrospectively summarized the 21 patients with hilar cholangiocarcinoma, who underwent total laparoscopic radical resection of hilar cholangiocarcinoma in our Hospital from Oct 2017 to April 2019. Collected the clinical data of those patients, including 9 cases of Bismuth type Ⅰ,10 cases of Bismuth type Ⅱ, and 2 cases of Bismuth type Ⅲb.
: Total laparoscopic radical resection of hilarcholangiocarcinoma were performed successfully. The procedure was finished within a time of (211.3±87.5) min and with an intraoperative blood loss of (132.3±59.1) ml.There was no death case during the perioperative period. All the patients had the R0 resection and the numbers of dissected lymph nodes were 13.4±2.7. The postoperative occurred in 2 patients, they were all cured spontaneously in one week, and there was no perioperative death.All patients were followed-up regularly within 3-24 months . One of them recurred within 12 months after the operation. The remaining patients have survived well so far.
Under the operation of the experienced surgeon, total laparoscopic radical resection of hilar cholangiocarcinoma is safe, feasible and effective in the short term.
PB01-15 Construction and Validation of a CIMP-Related Prognostic Signature for Cholangiocarcinoma
Ze-Yang Ding, China

Z.-Y. Ding, G.-X. Li, B. Zhang, X.-P. Chen
Hepatic Surgery Center, Tongji Hospital of Tongji Medical College of Huazhong University of Science and Technology, China

Background: Cholangiocarcinoma (CCA) presents tremendously high mortality. Its prognosis is unfavorable because of lacking in potential biomarkers for prognostic prediction.
Methods: CCA patients in GEO cohort were categorized into two subtypes. Differentially expressed and methylated genes were identified, and the impact of DNA methylation in trans-regulating gene expression were investigated. Finally, a CIMP-related methylation signature for CCA (CMSC) was trained in GEO and validated in Tongji cohort.
Results: A subset of patients with CIMP-H were identified, correlated with unfavorable prognosis. Gene enrichment analysis implied the potential mechanism of CIMP as a promoter in carcinogenesis via regulating proliferation. The trans-regulation among differentially methylation CpG sites and genes, with the same changing trends was positively correlated, while the contrary circumstances was predominantly dominated by negative correlation. Notably, CMSC based on four genes could significantly classified CCA patients into low- and high-risk groups in GEO cohort and the robustness of CMSC was validated in Tongji cohort. The result based on receiver operating characteristic analysis further indicated the CMSC presented highly sensitive and specific prediction of prognosis in CCA.
Conclusion: our work highlighted the clinical significance of CMSC in predicting the prognosis of CCA.
PB01-16 Arterial Enhancement Pattern Predicts Survival in Patients with Unresectable Intrahepatic Cholangiocarcinoma and Resected Intrahepatic Cholangiocarcinoma
Elena Panettieri, United States

E. Panettieri1, B.J. Kim1, J. Velasco1, Y. Kawaguchi1, H. Kang2, V. Cox2, S. Wei1, M. Javle3, J.N. Vauthey1
1Surgical Oncology, The University of Texas MD Anderson Cancer Center, United States, 2Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, United States, 3Medical Oncology, The University of Texas MD Anderson Cancer Center, United States

Background: Several studies showed an association between vascularity and prognosis in resectable mass-forming intrahepatic cholangiocarcinoma (IHCC). Prognostic utility of arterial enhancement in unresectable IHCC was never reported. Aim of this study was to determine if arterial hypervascularity confers a prognostic benefit in patients with unresectable IHCC and to corroborate previously reported positive prognostic effect in patients resected for IHCC.
Methods: All patients treated at single institution for IHCC between 2003 and 2015 with computed tomography (CT) dynamic enhancement at diagnosis were included. A resected Surgical (n=55) and an unresectable Medical (n=89) cohort were identified. After review by two radiologists, tumor vascularity was classified by total percent arterial enhancement (Hypervascular>50%, Peripherally Enhancing 10-50%, Hypovascular< 10%). Overall survival (OS) was the primary outcome for comparison between tumor vascularity.
Results: Unresectable patients were more frequently male (55.2% vs. 32.1%, p=0.01), with higher level of CA 19-9 at diagnosis (5470.7 ± 18826.8 U/mL vs. 629.4 ± 2570.9 U/mL, p=0.002) and larger radiologic tumor size (mean: 10.8 ± 3.8 cm vs. 6.3 ± 2.8 cm, p< 0.001). In both cohorts, OS was significantly higher in patients with hypervascular when compared to hypovascular tumors (Medical: p=0.030; Surgical p=0.038). There was no significant difference between tumors with hypervascular and peripheral enhancement (Medical: p=0.096; Surgical p=0.157) or peripheral enhancement and hypovascular tumors (Medical: p=0.396; Surgical p=0.297).
Conclusion: In resectable and unresectable patients with IHCC, hypervascularity at arterial CT phase represents a surrogate for prognosis. Appropriate preoperative imaging predicts favorable survival in one-third of patients undergoing resection for IHCC.
PB01-17 More than Four Lymph Node Metastases in Hilar Cholangiocarcinoma Still Had a Poor Prognosis
Yukihiro Iso, Japan

Y. Iso, Y. Sakuraoka, T. Shiraki, T. Shimizu, S. Sato, M. Niki, S. Mori, T. Aoki, K. Kubota
Second Department of Surgery, Dokkyo Medical University, Japan

Background: The hilar cholangiocarcinoma is advanced stage at the time of diagnosis. Although surgical resection is a golden standard of the treatment,
however the significance of resection from an oncological point of view for patients
with multiple lymph node metastasis is uncertain. In this study, we retrospectively
reviewed our experiences of resected cases of hilar cholangiocarcinoma.
Materials and methods: Between April 2000 and December 2018, liver resections
for 87 cases of hilar cholangiocarcinoma were performed. 59 cases underwent extended right hepatic lobectomy (ERHL), and 28 cases underwent extended left hepatic lobectomy (ELHL).
Results: The overall 5-year survival rates (5-SR) was 40.0 %. There was no
significant difference in the 5-year survival rate between the ERHL and ELHL cases.
Pathological examination revealed that there were 7 cases of UICC stage I, 49 cases of
stage II, 21 cases of stage IIIC, and 10 cases of stage IVA. Each stage revealed no
significant differences in 5-SR. Clinicopathological findings revealed no significant
differences in 5-SR between patients with those positive or negative for tumor
differentiation, tumor depth, tumor size, tumor infiltration, lymphatic invasion, venous
invasion, plexnerve invasion, and lymph node metastasis. However, analysis based on
the number of lymph node metastases showed that 76 cases were 3 or less and 11 cases were 4 or more, there was a significant difference in 5-SR (p = 0.011).
Conclusion: Surgical resection is crucial matter for hilar cholangiocarcinoma. However, more than 4 lymph node metastases in hilar cholangiocarcinoma still had a poor prognosis.
PB01-18 Prognostic Nutritional Index (PNI) Was Associated with Postoperative Survival Rate in Hilar Cholangiocarcinoma
Yukihiro Iso, Japan

Y. Iso, Y. Sakuraoka, T. Shiraki, S. Sato, M. Niki, S. Mori, T. Aoki, K. Kubota
Second Department of Surgery, Dokkyo Medical University, Japan

Background: Radical resection of hilar cholangiocarcinoma still has high complications and mortality. In this study, we retrospectively reviewed our experiences of resected cases of hilar cholangiocarcinoma, in terms of Prognostic Nuritional Index (PNI) and the outcome.
Materials and Methods: Between January 2001 and February 2018, liver resections for 89 cases of hilar cholangiocarcinoma were performed at our department. (1) The preoperative PNI was analyzed, and the median survival time (OS) between the two groups with a Cut Off value of 40 was compared. (2) Statistical differences in the preoperative PNI values, frequency of perioperative complications based on Clavien Dindo classification (CD), and survival rate for the two groups of our clinical path induction cases and non-induction cases investigated.
Results: (1) The 5SR in 45 cases less than PNI40 were 26 months, 23%, and in 44 cases more than PNI40, it was 127 months, 53% (p = 0.01). (2)PNI was 40 in patients with clinical path, 37 in non-introduced patients (p = 0.08), and the frequency of CD3 or higher was 24 (48%) in patients with introduction and 12 (63%) (p = 0.52).
Conclusions: A correlation between preoperative nutritional status and prognosis was suggested in hilar cholangiocarcinoma, and PNI of 40 or more was associated with better OS.
PB01-19 Tumor Infiltration Was Associated with Postoperative Survival Rate in Distal Bile Duct Carcinoma
Maiko Niki, Japan

M. Niki, Y. Iso, Y. Sakuraoka, T. Shiraki, T. Shimizu, S. Sato, S. Mori, T. Aoki, K. Kubota
Second Department of Surgery, Dokkyo Medical University, Japan

Background: The distal bile duct carcinoma is usually in the advanced stage at the time of diagnosis. Although surgical resection is a golden standard of the treatment, the recurrence rate is still high resulting in a poor prognosis. In this study, we retrospectively reviewed our experiences of resected cases of distal bile duct carcinoma, in terms of clinicopathological features and the outcome.
Materials and Methods: Between April 2000 and October 2019, pancreatoduodenectomy (PD) was performed for 109 cases of distal bile duct carcinoma at our department. Of these, 86 cases underwent non-residual tumor surgery (R0).
Results: There were 61 males and 25 females with a median age of 69.0 years. The median operation time was 503.5 min and the median operative blood loss was 696.5 ml. The overall 5-year survival rate (5-SR) was 47.4 %. Pathological examination revealed that there were 9 cases of UICC stage I, 53 cases of stage IIA, 22 cases of stage IIB, and 2 cases of stage IIIA. Each stage revealed no significant difference in 5-SR. Clinicopathological findings revealed no significant differences in 5-SR between patients with those positive or negative for tumor size, lymphatic invasion, vein invasion, and lymph node metastasis. However, tumor infiltration positive cases were associated with poor prognosis (P=0.028). The results revealed that tumor infiltration was associated with postoperative mortality (odds ratio, 2.024; 95% CI, 1.061-3.859; P= 0.032).
Conclusions: Tumor infiltration was associated with postoperative survival rate in distal bile duct carcinoma.
PB01-21 Pancreaticoduodenectomy for Recurrence of Distal Bile Duct Cancer after Bisthmus Type IIIa Hilar Cholangiocarcinoma Operation: A Case Report
SeungHwan Lee, Korea, Republic of

S. Lee, S.H. Joo
Department of Surgery, Kyung Hee University Hospital at Gangdong, Korea, Republic of

Introduction: Hilar cholangiocarcinoma is a relatively rare tumor with a poor prognosis and few long-term survivors. Although recent advances in imaging diagnosis, surgical techniques, and perioperative management can result in increased resectability and improved surgical outcomes, patients who had operation still have risk of cancer recurrence. Local recurrence, following a resection for cancer of the bile duct, is usually incurable because second curative surgery being almost impossible.
Method: We have experienced a good prognosis case after reoperation for bile duct cancer recurrence and presented in this study. The medical records and clinical outcomes of patients were retrospectively reviewed.
Results: The patient, a 63-year-old woman, had undergone curative right hepatectomy, caudate lobectomy, bile duct resection with hepaticojejunostomy for hilar cholangiocarcinoma bisthmus type IIIa. Histological examination revealed a T1 well-differentiated adenocarcinoma with intraductal papillary neoplasm background and all resection margins were negative. The recurrence at the site of intrapancreatic bile duct was identified 19 months after first operation. We performed a pancreaticoduodenectomy and histological examination revealed a 2cm sized moderately differentiated adenocarcinoma with intraductal papillary neoplasm background. The patient is being followed up for 4 years and 10 months without recurrence after second operation.
Conclusion: It is concluded that a secondary surgical resection is possible in selected patients with recurrent bile duct cancer, mostly of the papillary type. A primary operation for bile duct cancer should be performed with a wide surgical margin, and secondary curative surgery could be considered whenever possible in selected cases of recurrence.
PB01-22 Analysis of Recurrence in Patients who Underwent Curative-intent Resection for Perihilar Cholangiocarcinoma
Kizuki Yuza, Japan

K. Yuza, J. Sakata, K. Toge, Y. Hirose, H. Ishikawa, K. Miura, K. Takizawa, T. Kobayashi, T. Wakai
Division of Digestive and General Surgery, Niigata University Graduate School of Medical and Dental Sciences, Japan

Introduction: This study aimed to investigate the patterns of recurrence and to evaluate factors associated with the time to recurrence in resected perihilar cholangiocarcinoma patients.
Methods: A retrospective analysis was conducted on 138 patients undergoing curative-intent resection of perihilar cholangiocarcinoma. The median follow-up time was 115 months.
Results: During the follow-up period, 77 patients (56%) relapsed and the 5-year recurrence rate was 61%. Of 77 patients, 71 (92%) relapsed within 5-years after resection. Distant recurrence was detected in 44 patients (57%), whilst locoregional recurrence in 21 patients (27%), and the both in 12 patients (16%). The sites of distant recurrence were the liver (n = 17), peritoneum (n = 16), distant lymph nodes (n = 14), and lung (n = 9). On multivariate analysis, age (hazard ratio [HR] 1.7, P = 0.039), venous invasion (HR 1.9, P = 0.01), primary tumor status (HR 2.2, P = 0.001), and number of positive nodes (1-3: HR 1.8, P = 0.001, ≥ 4: HR 3.7, P = 0.028) were independent factors associated with time to recurrence. The treatment for the 77 relapsed patients were surgery (n = 8), chemotherapy (n = 41), and best supportive care (n = 28). The 3-year overall survival after recurrence was 38%, 4%, and 0%, respectively (P < 0.001).
Conclusions: More than half of patients with perihilar cholangiocarcinoma experience recurrence after curative-intent surgery, and these recurrences occur mostly within 5 years. Adjuvant strategies should be considered, especially for patients with venous invasion, extensive primary tumor, and nodal metastasis.
PB01-23 Oncologic Benefit of Frozen Section of Proximal Bile Duct Margin in Perihilar Cholangiocarcinoma
Sunhawit Junrungsee, Thailand

S. Junrungsee1, L. Adireklarpwong2, W. Lapisatepun2, A. Chotirosniramit2, N. Lertprasertsuke3, S. Kongkarnka3, K. Wannasai3
1Hepatobiliary-Pancreas Surgery and Liver Transplantation, Chiang Mai University, Thailand, 2Hepatobiliary-pancreas Surgery and Liver Transplantation, Chiang Mai University, Thailand, 3Pathology, Chiang Mai University, Thailand

Introduction: R0 resection is the best chance of prolonging the survival of cholangiocarcinoma patients. Frozen section of bile duct margin often be used to determine the histology of the bile duct to achieve R0 resection, but the clinical benefit remains controversial.
Methods: All 132 patients underwent hepatectomy for perihilar cholangiocarcinoma between January 2006, and December 2019 were analyzed. Resection status, the accuracy of the frozen section, surgical variables, prognostic factors, survival, and recurrence were evaluated.
Results: There were 39 patients in the frozen group and 93 patients in the non-frozen group. R0 status in the frozen section group was higher than the non-frozen section group but not significant (48.72 vs. 35.48 percent) (p= 0.175). Median survival in both groups was 24 and 17 months that tend to be better in the frozen section group, although there was no statistically significant difference (p= 0.25). In all populations, the median survival of R0 resection patients was better than R1 resection patients (32 vs. 13 months) (p= 0.001). All three patients in the secondary R0 group are still alive and have no recurrence. The median follow up time in the frozen section, and the non-frozen section group was 19.12 and 77.67 months.
Conclusions: The clinical benefit of the frozen section of the proximal bile duct margin is still inconclusive. The frozen section analysis tends to increase the number of R0 resection and prolong survival. The frozen section should be done if possible for increasing the R0 resection rate.
[Overall survival of the cholangiocarcinoma patients underwent frozen section analysis according to r]
PB01-25 Survival Analysis of Hilar Cholangiocarcinoma after Curative Surgical Resection Focused on Advanced Stage
Koo Koo, Korea, Republic of

J.W. Lee, K.S. Ahn, T.-S. Kim, Y.H. Kim, K. Koo
Division of HBP Surgery, Surgery, Keimyung University Dong-San Hospital, Korea, Republic of

Background/Aims: Hilar cholangiocarcinoma is known as a tumor showing poor prognosis despite curative surgical resection. Furthermore, many patients are diagnosed at advanced stage of disease, many of them are Bismuth type IV. Most of them are unresectable, and shows poor prognosis in spite of extensive surgical resection.
Materials/Methods: We retrospectively reviewed the 107 patients who were undergone surgical resection for hilar cholangiocarcinoma between 2001 and 2017. We did survival analysis according to various clinical factors including type of surgical resection and clinicao-pathological factors.
Results: A total of 107 patients were classified according to the Bismuth type, there were 3(2.8%) of type I, 10(9.4%) of type II, 74(70%) of type III and 19(17.9%) of IV. Five-year overall survival was 34.4% and 5-year disease free survival was 28.0% after surgical resection. In multivariate analysis of prognostic factors, CA19-9 elevation, histologic grade, lymphovascular invasion, and portal vein invasion were independent poor prognostic factors for both disease free and overall survival. There were no significant survival difference according to Bismuth type and gross pathologic type. Of note, for the patient who have Bismuth type IV, 5-year overall survival was 38.4% and it was not significantly different between R0 (n=4, 66.7%) and R1 (n=15, 33.3%) resection.(P=0.740).
Conclusions: There are a lot of R1 resection despite strong endeavor to achieve R0 resection for the patients including high proportion of advanced hilar cholangiocarcinoma like Bismuth type IV. However, the overall survival of entire cohort after extensive surgical resection is acceptable.
PB01-26 A Case of Hilar Cholangiocarcinoma Undergoing Curative Resection after Approximately One Year of Multidisciplinary Therapy
Mie Hamano, Japan

M. Hamano1,2, S. Katagiri2, M. Oota2, S. Onizawa2, Y. Niwa2, T. Sugishita2, T. Araida2, M. Yamamoto3
1Surgery, Japan Community Health Care Organization Tokyo Joto Hospital, Japan, 2Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University Yachiyo Medical Center, Japan, 3Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Japan

A 68 year-old women with obstructive jaundice was referred to our hospital for further examination and treatment.
Computed tomography(CT) scan revealed dilatation of the intrahepatic bile duct, and thickening and enhancement of walls were observed at the liver hilum.
Since bile drainage could not be performed using endoscopic retrograde cholangiopancreatography(ERCP), percutaneous transhepatic biliary drainage(PTCD) was implemented.
We diagnosed hilar cholangiocarcinoma of Bismuth type IV based on imaging from the PTCD tube, requiring a right trisegmentectomy.
Since the remaining liver volume was insufficient for resection, percutaneous transhepatic portal vein embolization(PTPE) was perfomed.
Although volume of the liver lateral segment increased, the patient was determined inoperable due to low bile production, and chemotherapy (Gem + CDDP) was implemented without surgery starting on March 2, 2017.
During chemotherapy, the patient suffered cholangitis and required hospitalization several times, but no exacerbation of the damage was found in bile duct imaging. When bile and liver volume was measured again in November, the patient was determined operable. In January 2018, a right hepatic trisegmentectomy, caudal lobectomy, and biliary tract reconstruction were performed. S-1 was administered after surgery. Currently, approximately 2 years have passed, and the patient remains recurrence-free.
In this case of an inoperable patient with hilar cholangiocarcinoma, a successful curative resection was performed by implementing PTPE in combination with chemotherapy while waiting for sufficient recovery of liver function. Although it took approximately one year until the operation could be performed, this result was achieved by continuing the treatment without giving up.
PB01-27 The Impact of Portal Vein Resection on Postoperative Outcome of Hilar Cholangiocarcinoma
Ki Beom Kim, Korea, Republic of

K.B. Kim, D.J. Park, N. Kim, S.H. Shin, I.W. Han, D.W. Choi
Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea, Republic of

Introduction: Concomitant Portal vein resection (PVR) with major hepatic resection could increase the rate of curative resection in hilar cholangiocarcinoma (HCCA). However, the role of PVR is still debatable because it could increase risk of postoperative morbidity. This study aimed to analysis the efficiency of combined PVR for HCCA in terms of postoperative complications and survival rate.
Methods: From January 2005 to December 2016, 418 patients had performed surgery for HCCA at Samsung Medical Center. Among them, 235 patients who underwent major hepatic resection with curative intent were finally analyzed retrospectively (patients with PVR, n=35; patients without PVR, n=200).
Results: There was no significant difference in postoperative complications between two groups. Patients with PVR were likely to have more advanced HCCA (T3: 40% vs. 12%, p< 0.001; nodal metastasis: 60% vs. 28%, p< 0.001), but obtained more curative resections (positive resection margin; 5.7% vs. 11.5%, p= 0.002). There was no significant difference in 5-year survival rates with or without PVR. After multivariate analysis, EBL > 600ml (HR= 1.688, 95% CI 1.133- 2.514, p= 0.010), T3 diseases (HR= 2.403, 95% CI 1.540- 3.747, p= 0.001), nodal metastasis (HR= 2.941, 95% CI 1.964- 3.747, p= 0.001), and poorly differentiated carcinoma (HR= 1.890, 95% CI 1.260- 2.836, p= 0.002) were identified as independent risk factors for survival after resection.
Conclusions: PVR does not increase postoperative morbidity, and showed similar oncologic outcomes despite of more advanced disease state in patients with HCCA. After careful patients' section, concomitant PVR could be beneficial for HCCA patients.
PB01-28 Identification of Dysregulation of Iron Metabolism and Post-translational Modifications via Bile in Cholangiocarcinoma
Keun Soo Ahn, Korea, Republic of

K.S. Ahn1, J.Y. Han1, K.J. Kang1, Y.H. Kim1, T.-S. Kim1, W.-K. Baek2, S.-I. Suh2
1Keimyung University Dong-San Hospital, Korea, Republic of, 2Microbiology, Keimyung University School of Medicine, Korea, Republic of

Background: Cholangiocarcinoma (CCA) is a highly malignant cancer of the biliary tract with a poor prognosis. Herein, we investigated possible mechanism of extrahepatic CCA (eCCA) by dysregulated iron metabolism and post-translational modifications (PTMs) and evaluated potential biomarkers in the bile fluid for diagnosis of eCCA and differentiation between eCCA and benign biliary disease.
Methods: From August 2018 to April 2019, we obtained bile fluids from 46 patients; 28 patients with eCCA (eCCA group) and 18 patients with common bile duct stone (Control group) via percutaneous transhepatic biliary drainage.
Results: The remarkable difference of PTMs was that FNTA which means prenylated cysteine as regulator was significantly decreased in eCCA than that of Control. In addition, level of GSH, peroxide, GPX and ferrous iron [Fe+2] were significantly depleted in eCCA than Control. These results demonstrate that PTM, dysregulated iron metabolism and GPX-regulated ferroptosis with GSH depletion through cysteine modification in bile are possible mechanisms of eCCA. Liquid Chromatography (LC)-Mass Spectrometry (MS) analysis, several oncogenic pathways including MYC target, apoptosis, fatty acid metabolism, P53 and mTORC1 were enriched in eCCA.
Conclusions: In conclusion, redox-dependent modification of cysteine and ferroptosis in bile fluids are possible mechanisms of eCCA. Several protein and oncogenic pathways related to PTM which are seen in eCCA tissues were also enriched in bile fluids. It suggests that bile fluid represents the oncogenic characteristics of eCCA tissues. Therefore, bile fluids have a role of a biomarker for diagnosis in eCCA, especially, differentiation of eCCA from benign biliary stricture.
PB01-29 Postsegmentectomy for a Local Recurrence of Hilar Cholangiocarcinoma after Central Bisegmentectomy and Caudal Lobectomy
Takeshi Kano, Japan

T. Kano, M. Hayasaka, S. Hata, H. Yamaguchi, M. Teruya, M. Kaminishi
Showa General Hospital, Japan

Introduction: Surgical resection is the only curative treatment for hilar cholangiocarcinoma but the possibility of local recurrence is high. The standard treatment for recurrent hilar cholangiocarcinoma after operation is chemotherapy and repeated resection is rarely performed. We herein report a rare case that re-hepatectomy was done for a local recurrence of hilar cholangiocarcinoma after central bisegmentectomy and caudal lobectomy.
Methods: A report of a case.
Results: A 75-year-old woman developed hilar cholangiocarcinoma and underwent extrahepatic bile duct resection with concomitant central bisegmentectomy and caudal lobectomy. The histopathological examination confirmed that R-0 resection had been achieved. After 18 months of the operation, computed tomography(CT) showed a local recurrence of the tumor in the posterior segmental branch of the intrahepatic bile duct with the portal vein invasion. The recurrent tumor was localized only in the region and we decided to operate again. The tumor was resected with the posterior segment, the portal vein and the hepaticojejunosotomy. The patient had an uncomplicated postoperative recovery and was discharged home.
Conclusion: We successfully performed re-hepatectomy for a local recurrence of hilar cholangiocarcinoma. As far as we know, such a case has not been reported. In the first operation, we chose not extended right hepatectomy nor extended left hepatectomy but central bisegmentectomy and as a result, remnant liver volume was spared. As a result, she could undergo curative major hepatectomy again.
PB01-31 Imaging Evaluation of the Tumor Progression in 24 Cases with Peri-hilar Cholangiocarcinoma after Preoperative Biliary Drainage
Chao Liu, China

G.-Z. Shi1, X.-D. Shi2, Q.-B. Tang2, H.-M. Lin2, J. Sun2, C. Liu2
1Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, China, 2Biliary Pancreatic Surgery, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, China

Introduction: Preoperative biliary drainage is essential for the radical treatment of peri-hilar cholangiocarcinoma. However, the drainage process may take more than one month. The aim of this study was to justify the benefit of improving liver function over tumor progression by biliary drainage.
Method: From December 1st, 2018 to November 30th, 2019, 24 jaundiced patients with peri-hilar cholangiocarcinoma were treated at the department of biliary pancreatic surgery, Sun Yat-sen Memorial Hospital. Preoperative biliary drainage was performed for each case, and each had contrast-enhanced CT before the biliary drainage and the laparotomy, respectively. The tumor progression on imaging was evaluated and marked according to the new staging system from the International Cholangiocarcinoma Group.
Results: All 24 patients (11 females and 13 males) underwent biliary drainage, including 12 with ENBD, 7 with PTCD, 5 with ENBD and PTCD. Average serum bilirubin level before and after drainage was 249.0 ±122.2µmol/L and 49.4 ±19.2µmol/L, respectively. The drainage time was 38.7±21.1 days(4 patients over 60 days). Tumor progression occurred at 4 of 24 patients, 2 of whom diagnosed as ICC with hilar involvement. Eight patients had unresectable mass, and 16 patients received large range hepatectomy with 0% mortality. The R0 resection rate was 62.5%(10/16). PV and HA reconstruction rate was 62.5%(10/16) and 25.0%(4/16), respectively. The hypohepatia and abdominal infection was 18.8% and 18.8%, respectively.
Conclusions: Most patients with peri-hilar cholangiocarcinoma had no tumor progression during biliary drainage, and this process could result in the increasing radical resection rate and decreasing mortality and morbility.
[Biliary drainage, surgical resection, and tumor progression on imaging of 24 patients]
PB01-32 Optimal Surgery for Early Ampullary Carcinoma Based on a Pathological Examination Following Resection
Norihisa Kimura, Japan

N. Kimura, K. Ishido, T. Wakiya, H. Nagase, K. Hakamada
Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan

Introduction: The aim of this study was to investigate whether partial resection (PR) instead of pancreaticoduedenectomy (PD) is acceptable for early (Tis-T1) ampullary carcinoma (AC).
Methods: Of 101 patients who underwent resection for AC between January 1985 and December 2018, 40 patients with early AC (Tis: 2; T1a: 18; T1b: 20) and 16 patients treated with PR were assesed. In addition, the lymphatic vessel distribution in the ampulla of Vater was investigated immunohistologically using D2-40.
Results: The 5-year survival rate was 100% and 87.4% in the Tis-T1a and T1b patients, respectively. On pathological examination, 10.0% (Tis-T1a: 0%; T1b: 20.0%) were lymph node (LN) metastasis (+), 20.0% (Tis-T1a: 0%; T1b: 40.0%) were lymphovascular invasion (+), 5.0% (Tis-T1a: 0%; T1b: 10.0%) were microvascular invasion (+), and 0% were perineural invasion (+). For the tumor differentiation, papillary or well differentiated tumors were found in all Tis-T1a patients, but moderate in 35.0% of the T1b patients. On immunohistological examination, abundant capillary lymphatic vessels were present in the mucosa of the ampulla of Vater. In the 16 patients treated with PR, the final pathological diagnosis was T1a in 12, pT1b in 1, and pT2 in 3, and the 4 non-T1a patients all died of recurrence.
Conclusions: For T1b AC, PD may be the standard treatment because of the frequencies of LN metastasis and lymphovascular invasion. Abundant lymphatic capillaries in the mucosa of the ampulla of Vater and difficulty with preoprative diagnosis of the invasion depth indicate that PR may not be acceptable for Tis-T1a AC.
PB01-33 The Preoperative Biliary Drainage with Endoscopic Naso-Biliary Approach Is Appropriate for the Patients with Hilar Cholangiocarcinoma
Shuichi Aoki, Japan

S. Aoki, K. Nakagawa, K. Masuda, H. Ohtsuka, M. Mizuma, H. Hayashi, T. Morikawa, F. Motoi, M. Unno
Department of Surgery, Tohoku University Graduate School of Medicine, Japan

Background: The preoperative biliary drainage (PBD) for hilar cholangiocarcinoma (CCA) in the jaundiced patient is controversial because of its increased postoperative infection, seeding along the percutaneous tract and delayed therapy.
Aim and Method
: To compare the clinical outcomes between the patients with and without PBD, the morbidity and prognosis of the 312 patients who underwent surgical resection of CCA from 1991 to 2019 were analyzed.
: Of the total cohort, the endoscopic (E group) and percutaneous (P group) PBD were underwent in 174 and 81 patients, respectively, while no PBD (N group) was needed in 57 patients. Between these groups (E vs P vs N group), the wound infection rate is significantly higher in P group (22.5vs15.4vs39.1%, p=0.009) but no differences were detected in other post-operative morbidities. In survival analysis, the P group showed worse prognosis compared to E or N group (median OS: 44.4vs22.6vs49.3m: p=0.003). Among 174 patients of E groups, endoscopic naso-biliary drainage (EN) and endoscopic retrograde biliary drainage (ER) were performed in 116 and 20 patients, respectively. In 38 patients, EN was initially performed but converted to EN due to cholangitis (ER/EN). Between these 3 groups (EN vs ER vs ER/EN group), the bile leakage from liver transection surface and pancreatic fistula was more frequently occurred in ER group (25.0vs26.3vs9.6%, p=0.018 and 25.0vs15.8vs9.6%, p=0.048, respectively).
Conclusion: PBD provides no adverse impacts in morbidity and prognosis for CCA patients. The EN drainage, not percutaneous, is preferable in terms of decreased perioperative morbidities.
PB01-34 Effect of Margin Status on Survival after Resection of Hilar Cholangiocarcinoma in the Modern Era of Adjuvant Therapies
Michael Watson, United States

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

Introduction: Previous studies of patients with perihilar cholangiocarcinoma (PHC) have shown survival disadvantage for R1 resection. New adjuvant treatments improve survival and may offset the deleterious effects of R1 resection.
Methods: Patients with PHC between January 2008 and July 2019 were retrospectively reviewed. Demographics, preoperative treatment, perioperative otucomes, postoperative treatment, recurrence, survival, and follow up were collected. Patients with R0 and R1 resection were compared (R2 excluded). Kaplan-Meier (KM) analysis was used to compare overall survival (OS) and recurrence-free survival (RFS).
75 patients went to the operating room for resection and 34 (47.9%) were aborted for metastatic disease (17/34, 50%) or locally advanced disease (17/34, 50%). Of 41 resections, 18 patients (43.9%) had R1 resection. Age, sex, preoperative biliary drainage, tumor size, T stage, and N stage were similar between groups (all p>0.05). Rate of adjuvant therapy (R0 56.5% vs 61.1%; p=0.7672) was similar between groups. Complication rate and 30-day mortality were similar between groups (both p>0.05). Median RFS (R0 23.8 mon vs R1 23.3 mon; p=0.4309) and median OS (R0 30.6 mon vs R1 37.2 mon; p=0.2439) were similar between groups at similar median follow up time (R0 29.9 vs R1 28.5; p=0.5321). KM survival graphs for RFS and OS are displayed in figure 1, without statistically significant difference.
Conclusions: At our institution, patients R1 resection of PHC have similar RFS and OS to patients with R0 resection. This indicates that with use of modern adjuvant therapies, obtaining an R0 resection may not be absolutely required.
[Figure 1. Overall survival and recurrence-free survival for patients with R0 vs R1 resection margins]
PB01-36 An Experience of Laparoscopic Hepatopancreatoduodenectomy in Patient with Perihilar Cholangiocarcinoma
Jingdong Li, China

J. Li1, Y. Xiong2, C. Wu1
1Department of Hepatocellular Surgery, Affiliated Hospital of North Sichuan Medical College, China, 2Hepatobiliary Surgery, Affiliated Hospital of North Sichuan Medical College, China

Introduction: Surgical resection is the only curative treatment for perihilar cholangiocarcinoma (pCCA). Despite this poor survival rate and high morbidity and mortality, hepatopancreatoduodenectomy (HPD )is routinely performed. With recent progress in diagnostic procedures, surgical techniques and perioperative patient care, many studies have shown increased long-term survival rates following this aggressive procedure. However, to our knowledge, there has been no reported case of perihilar cholangiocarcinoma treated with laparoscopic hepatopancreatoduodenectomy(HPD). We recently had a patient who underwent a pure laparoscopic HPD for a type IV pCCA.
Methods: A 53-year-old female who was revealed the dilation of intrahepatic hepatic duct and a mass on the perihilar bile duct by abdominal magnetic resonance imaging (MRI). The patient was diagnosed with perihilar cholangiocarcinoma. The decision was to perform a pure laparoscopic extend right hemihepatectomy with caudate lobetectomy and pancreaticoduodenectomy was performed.
Results: Operative time was 660 minutes with 500 mL blood loss and 3.5 U red cell. Histological examination revealed a well differentiated mucinous adenocarcinoma without lymph-node metastasis and a negative margin of liver parenchyma and pancreas. She was recovered from a grade B pancreatic fifistula by conservative therapy and discharged post-operatively on day 20 in good health.
Conclusions: Complete laparoscopic HPD for pCCA is a challenging procedure. However, this procedure is safe and feasible in selected patients and when performed by surgeons with expertise in liver surgery and minimally invasive techniques.
PB01-39 A Case of Paraneoplastic Neurological Syndrome Improved Following Pancreatoduodenectomy for Cholangiocarcinoma

A. Kuroda, S. Hata, M. Hyasaka, H. Yamaguchi, M. Kaminishi
Department of Surgery, Showa General Hospital, Tokyo, Japan

Introduction: When patients with neoplasm have neurological symptoms, we must consider invasion or metastasizing of the tumors to the neurological system or drug side effects. But it is called paraneoplastic neurological syndrome (PNS) when we deny them. It is said that PNS develops by autoimmune mechanism with anti-tumor antibodies. Immunotherapy is not effective and a removal of the antigen stimulation by treating the tumor becomes the basic treatment. Still it is said that the effect of treatment is poor. Here we report a rare case of PNS with cholangiocarcinoma whose neurological symptoms improved after surgery.
Methods: Case report.
Results: A 67-year old male visited our outpatient hospital with symptoms of right homonymous hemianopsia, scintillating scotoma, and headache. Magnetic resonance imaging indicated encephalitis. Hepatobiliary enzymes increased by blood data at admission and diabetes was getting worse. Computed tomography showed the mass in the pancreatic head. After being hospitalized, he came to present with disturbance of consciousness, a convulsive seizure. Although immunoglobulin therapy was given, the improvement was poor. PNS due to cholangiocarcinoma of the distal bile duct was considered and he underwent pancreatoduodenectomy on 14 days after hospitalized. After that operation the neurologic symptoms promptly improved and he was discharged on the 19th hospitalized day. The pathological diagnosis was cholangiocarcinoma invading the pancreas and we achieved curative resection.
Conclusion: We should consider surgical resection for the patient with PNS when curative resection can be expected.
PB01-42 Developing Primary Culture from Human Cholangiocarcinoma
Cataldo Doria, United States

B. Dalvano1, T. Block1, J. Chung2, X. Yang1, A. Sayeed1, C. Doria2
1Blumberg Institute, United States, 2Capital Health, Cancer Center, United States

Background: Our goal is to isolate and expand tumor cells in culture and identify the spectrum of malignant attributes.
Methods: Fresh tumor tissue from Grade 3, Stage IA, intrahepatic CCA was minced and subjected to enzymatic digestion for 75 minutes at 37°C. Digested contents were filtered through a 40 µm filter and the cells in the filtrate after washing were plated in 6 well collagen coated dishes using Williams E. Media supplemented with 2% FBS and several growth factors. One batch of cells was immortalized by pBABE hTERT retroviral vector.
Results: Within 2-3 days, epithelial cells started propagating and cells grew up to 7 passages (P) over the course of two months both with (CCA-telo) or without (CCA) telomerase immortalization. Using qPCR analysis in P6 CCA/CCA-tel lines, expression profiles of liver cell specific markers like HP, ALB, APOA2, SERPINA1, and AFP were found to be very low,compared to HCC line HepG2 but exression of these was similar to lung adenocarcinoma A549 cell line. CCA line showed good telomerase expression however lower than CCA-telo line with exogenous telomerase induction.
Conclusions: Cells isolated from human CCA show good viability and propagated for up to 7 passages. Though cells exhibited typical epithelial and mesenchymal morphology, the cells did not show liver epithelial markers. CCA line appears to be spontaneously immortalized, independent of exogenous hTERT induction. The gene expression profile of malignant tissue, if retained by primary culture cells, could facilitate the development and testing of novel molecular targets for cholangiocarcinoma.
[Figure 1]
PB01-43 Investigation of the Lymphatic System in the Human Perihilar Bile Duct Region
Yuto Mitsuhashi, Japan

Y. Mitsuhashi, N. Kimura, K. Ishido, T. Wakiya, H. Nagase, K. Hakamada
Gastroenterological Surgery, Hirosaki University Graduate School of Medicine, Japan

Introduction: Perihilar cholangiocarcinoma has a poor-prognosis due to its frequent lymph node metastasis. The only cure is surgery, but local recurrence, peritoneal dissemination, and multiple organ recurrence are often observed even after tumor resection with sufficient lymph node dissection. On the other hand, little information is available regarding microanatomy of lymphatic system in the perihilar bile duct region.
Methods: We removed the liver and hepato-duodenal ligament from the dissected cadavers. The fine distribution and structure of the lymphatic vessels were investigated in the perihilar region by immunohistochemistry for lymphatic- (D2-40) and blood vascular- (CD31) specific markers and scanning electron microscopy.
Results: Lymphatic vessels were abundant throughout the hepatic artery. In the portal vein, lymph vessels were found abundantly in the wall on the ventral side, but lymph ducts in the wall decreased toward the dorsal side. Lymph ducts around the bile duct were present around the peribiliary vascular plexus (PBP), a capillary network around the bile duct. In the liver, immunostaining of CCL21, a chemokine that induces lymphocytes, and CCR7, its receptor, suggested the hepatic lymphatic fluid from the space of disse to the institution of the portal tract.
Conclusions: This study could have helped to elucidate the lymphatic network of the hilar part
PB01-44 Brachial Plexopathy: A Rare Presentation of Metastatic Cholangiocarcinoma

A. Zainal Mokhtar, I. Chik, F. Fahmy, A. Azman, Z. Zuhdi
Surgery, National University of Malaysia, Malaysia

Introduction: Metastatic brachial plexopathy is a rare occurrence, but its presentation may be confused with day to day ailments.
Methods: We report a patient who initially presented with worsening right shoulder pain, associated with right hand numbness and weakness, and was subsequently diagnosed with metastatic cholangiocarcinoma.
Results: Patient's initial presentation and diagnostic pathway is discussed in this report. As there has not been any cases reported prior, a possible cause of the plexopathy is considered.
Conclusion: Although rare, metastatic disease (with cholangiocarcinoma as one of the differential diagnosis) should be considered in patients' with prolonged bone pain.
PB01-45 Anatomical Liver Resections for Intrahepatic Cholangiocarcinomas: Perioperative Results and Survival
Gabriela Ochoa, Chile

G. Ochoa, A. Troncoso, E. Briceño, M. Dib, J. Martinez, N. Jarufe
Digestive Surgery, Pontifica Universidad Católica de Chile, Chile

Introduction: Intrahepatic cholangiocarcinma (ICC) is an infrequent neoplasm, whose incidence is increasing with a poor prognosis. The only curative management is surgery, however, only 1/3 of patients achieve negative margins.
Method: Retrospective cohort of 17 resected ICC cases, between 2006 to 2019 from Catholic University Hospital in Chile. The information was obtained from clinical reports. Analysis with descriptive statistics.
Results: Out of 17 patients, between 48 and 84 years-old, 2 with risk factors (chronic liver disease, iatrogenic bile duct injury) and 5 patients received neoadjuvant therapy. There were 4 extended right hepatectomies, 3 right hepatectomies, 4 extended left hepatectomies, 3 left hepatectomies, 2 bisegmentectomies (IV, V) and 1 left lateral sectionectomy. Mean operative time was 263 minutes and hospital stay average was 14,2 days. There was no 30-day mortality. The global morbidity was 41,2% (7 patients) and Clavien Dindo>IIIA complications were 17,6% (3 patients). Reoperations were 2 cases, for hemoperitoneum and for bile leak. The oncologic classification was Ia (1), Ib (1), II (4), IIIa (2), IIIb (8) y IV (1). There were positive lymph nodes in 8 cases, 1 with peritoneal metastases, 8 patients resulted R1 (47,1%) and 14 received adjuvant treatment. The global survival was 82,4% at 6 months, 46,7% at 1 year and 40% at 2 years, with a mean follow-up of 24,3 months.
Conclusion: The surgical treatment of ICC normally requires large anatomical liver resections, despite which, the incidence of R1 positive margins is high and could result in the poor prognosis of long-term disease.
[Survival Analysis with Kaplan Meier curves]
PB01-46 The Value of Modified Mesohepatectomy in the Treatment of Hilar Cholangiocarcinoma
CH Xiang, China

J. Dong1, C. Xiang2, S. Jin2, L. Wang2, S. Yu2
1Hepato-Pancreato-Biliary Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, China, 2Department of Hepatobiliary Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, China

Objective: To evaluate the feasibility and safety of modified mesohepatectomy for hilar cholangiocarcinoma.
Background: Hilar cholangiocarcinoma was often need trisegment hepatectomy when the tumor invasion range beyond P/U point. Mesohepatectomy was limited when the tumor invaded bilateral primary bile duct.
Method: From 2015 to 2019, 8 patients underwent mesohepatectomy due to HCCA, the clinical data including bleeding volume, postoperative complications and other information was analyzed. Modified mesohepatectomy consists of hepatectomy beyond P/U point and bile duct plastic technique.
1) Basic clinical data: Including 6 male and 2 female patients in this study. The average age was 68.38. Bismuth classification: 1 Type IIIA, 3 type IIIB, 4 type IV.
2) Surgical evaluation: 3 cases of IV + V + VIII,3 cases of IV and 1 case of V + VIII segment resection. The average resection rate of liver parenchyma was 30%,The median end of the bile duct is 4, The median of choledochojejunostomy after bile duct plastic was 2.
3) Postoperative complications: 1 case of Clavein IV (Liver dysfunction, bile leakage),3 cases of Clavein IIIA and 1 case of Clavein II because of bile leakage.
Conclusion: Modified mesohepatectomy showed excellent feasibility and safety in the treatment of III and IV HACC. Improved the cure rate whose FLV isn't enough to endure the aggressive hepatectomy. At the same time, it reduced the difficulty of choledochojejunostomy, ensured the damage control and the functional compensation of the remnant liver volume.
Funding: This clinical study was supported by Beijing Natural Science Foundation (7194338).
Keywords: Hilar cholangiocarcinoma, mesohepatectomy