Poster
Biliary 		  
PB02 Biliary: Gallbladder Cancer (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PB02-02 BRD4 Inhibitor and Histone Deacetylase Inhibitor Synergistically Inhibit the Proliferation of Gallbladder Cancer in vitro and in vivo
Shilei Liu, China

S. Liu1,2, W. Gong1,2
1Department of General Surgery, Shanghai Jiao Tong University School of Medicine, China, 2Shanghai Key Laboratory of Biliary Tract Disease Research, China

Introduction: Gallbladder cancer (GBC) is the most common and aggressive malignancy of the biliary tract worldwide. However, the current treatment for GBC is very limited, which makes the development and exploration of novel and effective anticancer agents for GBC treatment becomes vital. Here, we invested the anticancer effects of BRD4 inhibitor JQ1 and histone deacetylase inhibitor suberoylanilide hydroxamic acid (SAHA) on GBC both in vitro and in vivo.
Method: In this study, we conducted in vitro assays(CCK-8 assay, colony formation assay, Migration and invasion assay, flow cytometry for apoptosis and cell cycle analysis, qRT-PCR and western blot) and in vivo assays(tumor xenograft modules and immunohistochemistry), which demonstrated BRD4 inhibitor JQ1 and histone deacetylase inhibitor SAHA synergistically inhibited the GBC cells both in vitro and in vivo.
Results: Our results showed that cotreatment with JQ1 and SAHA significantly inhibited proliferation, cell viability, metastasis, and induced apoptosis and G2/M arrest in GBC cells, but only minor effects in benign cells. In vivo, tumor volumes and weights of GBC xenograft models were significantly decreased after treated with JQ1 or SAHA, meanwhile the cotreatment showed the strongest effect. Further study indicated that the above anticancer effects was associated with the downregulation of BRD4 and suppression of PI3K/AKT and MAPK/ERK pathways.
Conclusions: These findings highlight JQ1 and SAHA as potential therapeutic agents and their combination as promising therapeutic strategy for GBC.
PB02-04 A Novel Staging System to Forecast the Cancer-Specific Survival of Gallbladder Cancer Patients
Yongcong Yan, China

Y. Yan, K. Mao, J. Lin, H. Liu, C. He, J. Wang, Z. Xiao
Sun Yat-sen University, China

Introduction: Gallbladder cancer (GBC) is one of the most aggressive malignant tumors, and there is no effective and convenient method for predicting cancer-specific survival (CSS). We aim to develop a novel nomogram staging system based on the positive lymph node ratio (pLNR) for GBC patients.
Methods: A total of 1,356 patients enrolled in the study. We evaluated the prognostic value of the pLNR and built a prognostic nomogram staging system based on the pLNR in the training cohort. The concordance index and calibration plots were used to evaluate model discrimination. The predictive accuracy and clinical value of the nomograms were measured by decision curve analysis (DCA). The CSS nomogram was further validated in an internal validation cohort.
Results: The pLNR was an independent prognostic factor for CSS based on Cox regression analyses. A prognostic nomogram that combined T classification, pLNR, M classification, histologic grade, live metastasis and tumor size was formulated with a c-index of 0.763 (95% CI, 0.728-0.798), while the c-indexes for the staging system of AJCC 8th, 7th, and 6th for CSS prediction were 0.718, 0.718, and 0.717, respectively. The calibration curves showed perfect agreement. The DCA showed that the nomogram provided substantial clinical value. The nomogram (the AUCs for one, three, and five years were 0.693, 0.716, and 0.726, respectively) showed high prognostic accuracy.
Conclusion: We have developed a formulated nomogram staging system based on the pLNR that allows more accurate individualized predictions of CSS for resected GBC patients than the AJCC staging systems.
PB02-06 A Rare Case of Gallbladder Paraganglioma with Hemorrhage
Chol Kyoon Cho, Korea, Republic of

C.K. Cho, Y.H. Lee
Surgery, Chonnam National University Medical School, Korea, Republic of

Introduction: Gallbladder paraganglioma is a very rare tumor and only a few cases have been reported so far. Most of these tumors are asymptomatic and confirmed incidentally after operation. The clinical significance of gallbladder paraganglioma is differential diagnosis with gallbladder cancer or other gallbladder tumor.
Methods: A 48-year-old woman presented with intermittent abdominal pain. The laboratory tests were all within normal range including tumor marker. MRI showed 8 cm sized mass lesion in gallbladder body and fundus with low signal intensity in T2-weighted images considered as hemorrhage. We planned a laparoscopic cholecystectomy under the impression of gallbladder tumor with hemorrhage.
Results: We performed laparoscopic cholecystectomy successfully. In the gallbladder lumen, several black stones less than 1 cm in diameter and large hematoma were observed. And about 1 cm sized polypoid lesion was detected in the fundus. In microscopic examination of polypoid lesion showes cuboidal cells including granular cytoplasm surrounded by a fibrous septum containing blood vessels. The chief cell was nested in the inside and the spindle shape sustentacular cells surrounded by the Zellballen cellular arrangement. Synaptophysin, CD56, chromogranin staining were strongly positive for chief cells. In the histopathologic examinations, the diagnosis was gallbladder paraganglioma with hemorrhage.
Conclusions: Gallbladder paraganglioma is extremely rare tumor and usually diagnosed incidentally after operation. We need to aware of this disease entity for differentiation of this tumor with other gallbladder tumors.
PB02-10 Outcomes and Prognostic Factors in Patients with Gallbladder Carcinoma with Multimodality Treatment
Sneha Jha, India

A. Pandey, S. Jha, S. Masood, S. Chauhan, D. Kumar, S. Kumar, S. M.M
Ram Manohar Lohia Institute of Medical Sciences, India

Introduction: India is a high incidence area for Gall Bladder Cancer (GBC). GBC has short median survivals reflecting its aggressive behaviour. Early GBC can be managed by radical surgery which is possible in 10% cases. The tumour is often unresectable at presentation requiring multimodality approach for management.
Methods: 173 inpatients of suspected GBC from January 2013 to July 2019 at a tertiary centre in North India were analysed. Patients were grouped as - Potentially resectable, Locally advanced unresectable and metastatic disease. Radical cholecystectomy was performed for resectable GBC. Duration of hospital stay, complications and Survival were analyzed.
Results: Out of 173 suspected GBC ,113 patients were resectable. Radical cholecystectomy was performed in 56 patients (72.7%) ,9 (11.6%) required bile duct excision, 6 (7.7%) additional organ resection. Major morbidity and mortality rate was 1.7% and 1.7% respectively. The estimated OS of stage I and II was 100% and 91.6%, respectively whereas 66.9% for stage III and 0% for stage IV disease. The median survival of stage I and II was 60.1 months which dropped to 23.9 months in stage IIIB and 6.3 months in stage IVB. Although adjuvant chemotherapy has increased the OS by 8.2 months but not statistically significant.
Conclusion: We are still facing challenges in early diagnosis as patients often presents late in our setting. Careful patient selection with combination of surgery and peri-operative chemotherapy has resulted in favourable outcomes in stage II/III disease. Potentially multimodality treatment may add meaningful survival for this disease with inherently aggressive tumor biology.
PB02-12 Clinicopathological Differences in T2 Gallbladder Cancer According to Tumor Location
Wan--Bae Kim, Korea, Republic of

W.-J. Kim, T.-W. Lim, P.-J. Park, S.-B. Choi, W.--B. Kim
Korea University Guro Hospital, Korea, Republic of

Background: We aimed to identify clinicopathological differences and factors affecting survival outcomes of stage T2a and T2b gallbladder cancer (GBC) and validate the oncological benefits of regional lymphadenectomy and hepatic resection in these patients.
Materials and methods: This single-center study enrolled patients who were diagnosed with pathologically confirmed T2 GBC and underwent curative resection between January 1995 and December 2017. Eighty-two patients with T2a and 50 with T2b GBCs were identified, and clinical information was retrospectively collected from medical records and analyzed
Results: Three- and 5-year overall survival rates were 96.8% and 96.8% and 80.7% and 80.7% in T2a and T2b groups, respectively (p=0.007). Three- and 5-year survival rates among all T2 GBC patients without and with lymph node metastasis were 97.2% and 94.4% and 81.3% and 81.3%, respectively (p=0.029). There was no difference in survival rates between the two groups according to whether hepatic resection was performed (p=0.320). However, in the T2b group, those who underwent hepatic resection demonstrated a better survival rate than those who did not (p=0.029). Multivariate analysis revealed that lymph node metastasis, vascular invasion, tumor location, and adjuvant chemotherapy were significant independent prognostic factors.
Conclusions: Hepatic resection was not always necessary in patients with peritoneal-side GBC. Considering the clinicopathological features and recurrence patterns of hepatic-side GBC, a systematic treatment plan, including radical resection and adjuvant chemotherapy, should be established.
PB02-14 Characteristics and Management of Incidental Gallbladder Cancer: Impact and Limitation of Laparoscopic Whole Layer Cholecystectomy
Jun Muto, Japan

J. Muto, K. Hashida, M. Yokota, Y. Nagahisa, S. Nishina, M. Okabe, H. Kitagawa, T. Park, K. Kawamoto
Department of Surgery, Kurashiki Central Hospital, Japan

Introduction: Incidental Gallbladder Cancer (IGBC) is a status of gallbladder cancer (GBC) that has not been diagnosed as cancer preoperatively. Efficacy of laparoscopic whole layer cholecystectomy (LWC) for early stage GBC is reported. However, there is no report about effect of LWC on IGBC. We are reporting the risk factors of recurrence of IGBC and strategy for IGBC from experience of a high-volume center in Japan.
Methods: We retrospectively investigated on 3166 patients who were undergone cholecystectomy with preoperative diagnosis of benign disease in our hospital from 2009 to 2018.
Results: Fifty-one patients (1.61%) were diagnosed as IGBC. Preoperative diagnoses were acute cholecystitis (16/1106, 1.45%), chronic cholecystitis (4/117, 3.42%), gallbladder polyp (19/151, 10.60%), adenomyomatosis (3/107, 2.80%) and gallbladder stone (9/1580, 0.57%). Post-operative recurrence was observed on 19 cases. Risk factors for recurrence on univariate analysis were bile spillage (p=0.001), advanced stage (p=0.002), positive surgical margin (p=0.005) and non-LWC (p=0.047). On multivariate analysis, bile spillage was only significant factor of recurrence (p=0.024, OR=11.43). No bile spillage was occurred on any of 10 patients performed LWC. Six patients of T1 were undergone LWC and no patients were relapsed. Risk factor of recurrence among advanced stage patients were non-additional resection (p=0.010) and bile spillage (p=0.036), but LWC was not significant (p=0.228).
Conclusion: Bile spillage was significant risk factor of recurrence on IGBC. LWC is an efficacious procedure on T1 IGBC, and LWC is recommended on IGBC suspected disease such as gallbladder polyp. For advanced stage, additional resection should be performed.
PB02-17 GLI2/Hedgehog Signaling Contributes to the Induction of Malignant Phenotype of Gallbladder Cancer
Shu Ichimiya, Japan

S. Ichimiya1, H. Onishi1, S. Matsushita2, S. Koga1, Y. Fujioka1, K. Nakayama1, A. Fujimura1, Y. Oyama1, M. Nakamura3
1Department of Cancer Therapy and Research, Graduate School of Medical Sciences, Kyushu University, Japan, 2Department of Surgery, Gokeikai Osaka Kaisei Hospital, Japan, 3Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Japan

Background: We have previously shown that Hedgehog (Hh) signaling is reactivated in GBC. However, which and how three GLI proteins; GLI1. GLI2 and GLI3 contribute to the induction of malignant phenotype of GBC is still unclear. To develop a new therapeutic strategy for refractory GBC, the biological significance of GLI1, GLI2 and GLI3 was investigated.
Materials:
1) In vitro experiment; GLI proteins were inhibited using siRNA. GLI expressing 3 GBC cell lines (NOZ, TGBC2TKB, and TYGBK−1) were used for invasion assay and proliferation assay.
2) In vivo experiment; In xenograft mice model, tumorigenesis of GLI inhibited cells (NOZ) was analyzed.
3) Clinical experiment; 67 patients with GBC who underwent curative surgical resection were enrolled in this study. Correlation between GLI expression and clinicopathological findings was analyzed immunohistochemically.
Results:
1) In vitro results; GLI2 siRNA but not GLI1/GLI3 siRNA transfection significantly inhibited the invasiveness and proliferation ability of GBC cells.
2) In vivo results; Tumor volume from mice injected with GLI2 siRNA transfected cells was significantly lower than that in control tumors.
3) Clinical results; The expression levels of GLI2 in human GBC specimens were higher than those in normal gallbladder tissue. GBC specimens with high GLI2 expression had significantly high level of PD-L1 expression and low number of infiltrated CD3 positive lymphocytes.
Conclusion: GLI2 contributes to the induction of malignant phenotype of GBC and could be a potential therapeutic target for GBC.
PB02-19 Extended Resections for Advanced Gallbladder Cancer: Results from a Nationwide Cohort Study
Elise de Savornin Lohman, Netherlands

H. Kuipers1, E. de Savornin Lohman2, D. Braat3, F. Daams4, J. Erdmann5, J. Hagendoorn6, B. Groot Koerkamp7, P. de Reuver2, M. de Boer1, National Gallbladder Cancer Collaborative
1Surgery, UMCG, Netherlands, 2Surgery, Radboudumc, Netherlands, 3Surgery, LUMC, Netherlands, 4Surgery, Amsterdam UMC, VUmc, Netherlands, 5Surgery, Amsterdam UMC, AMC, Netherlands, 6Surgery, UMC Utrecht, Netherlands, 7Surgery, Erasmus MC, Netherlands

Background: Extended resections (i.e. major hepatectomy and/or pancreatoduodenectomy) are rarely performed for gallbladder cancer (GBC) as outcomes remain inconclusive. Little data is available from Western centers. In this Dutch, multicenter cohort study outcomes of patients who underwent extended resections for locally advanced GBC are analyzed.
Design: Patients with GBC who underwent extended resection with curative intent from 2000 to 2018 were identified from the Netherlands Cancer Registry (NCR). Extended resection was defined as a major hepatectomy (resection of ≥ 3 liver segments) and/or a pancreatoduodenectomy. Post-operative morbidity, mortality, survival and characteristics of short- and long-term survivors were assessed.
Results: A total of 33 patients was included. R0-resection margins were achieved in 16 patients. Major post-operative complications (≥CD3A) occurred in 19 patients and post-operative mortality < 90 days in four. Recurrence occurred in 24 patients. Median overall survival (OS) was 12.8 months (95% CI 6.5 - 19.0). Two-year survival was achieved in 10 patients (30%) and 5-year survival in 5 patients (15%). Jaundice, common bile duct-, liver-, perineural- and perivascular invasion were associated with reduced survival. All (3) recurrence-free patients had R0 resection margins and no liver invasion.
Conclusion: Median OS after extended resections for advanced GBC was 12.8 months in this cohort. Although post-operative morbidity and mortality were significant, long term survival (≥ 2 years) was achieved in a subset of patients. Therefore, GBC requiring major surgery does not preclude long-term survival and a subgroup of patients benefit from surgery.
Age (IQR)64 (57- 69)
Gender (male)13 (39%)
ASA classification <319 (76%)
Pre-operative biliary drainage (yes)20 (61%)
Portal Vein Embolization performed5 (15%)
Hepatectomy12 (36%)
Extended hepatectomy7 21%)
Hepatectomy + pancreatoduodenectomy2 (6%)
Pancreatoduodenectomy + liver wedge resection21 (36%)
Portal vein reconstruction10 (30%)
[Patient and operative characteristics of GBC patients that underwent extended resection]

[A: Survival of patients with GBC and extended resection. B: Survival according to resection margin.]
PB02-20 Gallbladder Cancer in Australian Capital Territory: A 20 Years Analysis of Incidence, Management, and Outcomes
Krishanth Naidu, Australia

K. Naidu1,2, T. Yiu1, R. Shanmugasundaram2, J. Salim1, D. Yip2,3, S. Gananadha1,2
1Department of General Surgery - HPB Unit, Canberra Hospital, Canberra, Australia, 2Australian National University, Canberra, Australia, 3Department of Medical Oncology, Canberra Hospital, Canberra, Australia

Introduction: Gallbladder cancer (GBC) is a rare malignancy in Australia with an incidence of less than 6 per 100000 population. There is marked geographic variation in incidence with the majority of the literature from these endemic regions. The aim of the paper is to assess the incidence, characteristics and outcomes of GBC in a non-endemic region.
Methods: A retrospective review of all patients diagnosed with GBC in the Australian Capital territory over a 10-year period was undertaken. This included hospital medical records and a prospectively collected cancer database. Cases were also identified from ACT-wide pathology laboratories where specimens were sent for histological analysis. Adults with GBCs regardless of metastatic state were included. Patient characteristics including presenting features, histology, treatment received and survival were assessed.
Results: 58 GBCs (Primary=74.1%) were identified. The incidence of primary GBC was 2.7/100,000 person-years with a mean age of onset at 68.5 years with a female preponderance (~72.5%). The mean survival was 2.3 years with an overall five-year survival of 51%. 88.4% of patients were symptomatic with right upper quadrant pain and/or a mass, jaundice or weight loss. Incidental GBC was found in 11.6% of the patients. Adenocarcinoma was noted in 93% of primary cases with most being at Stage 3A on diagnosis. 60.5% underwent surgery.
Conclusion: GBC is rare cancer in the Australian population with majority of the symptomatic patients being diagnosed at a late stage. Incidental cancers are a significant proportion of patients. The overall outcome of this cancer is poor.
PB02-22 Analysis of the Cases with Carcinoma Gallbladder (CA GB) in a Tertiary Level Hospital of Nepal
Romi Dahal, Nepal

R. Dahal, B. Ghimire, P. Kansakar, R.S. Bhandari, P.J. Lakhey
GI and General Surgery, Tribhuvan University Teaching Hospital, Nepal

Introduction: Gallbladder cancer (GC) is a rare disease in some parts of world but is common in countries like Chile, Japan, India and Nepal. Nepal stands as one of the five countries with the highest mortality.
Methods: A retrospective analysis of the consecutive operated and non-operated admitted cases of GC in TUTH from 2018 to 2019 was done. Patient demographics, disease characteristics, diagnostic modalities and various curative and palliative treatment variables were analyzed.
Results: Of the 59 patients, 33 females (56%) outnumbered the 26 males(44%) with a male is to female ratio of 0.7:1. The median age at diagnosis was 56 years with younger than 60 years comprising 62.7% of the disease. Among all, the most common presenting symptom was abdominal pain followed by jaundice. Onset of first symptoms was within mean duration of 40 days (SD 37.45 days).
USG and CT availability (100%) lead to preoperative diagnosis in majority. Curative resection (extended cholecystectomy) was done in 16 (27%).The most common anatomic location of mass was fundic followed by neck. Of the advanced metastatic Ca GB in 30% of cases, the most common site of metastasis was liver. Most cases were adenocarcinoma with mean survival after diagnosis in advanced cases being 4.5 months.
Conclusion: CA GB is more common in Nepal, more among females and younger patients often presenting with pain abdomen and jaundice. Most are advanced at the time of diagnosis. Radical surgery can be offered to few patients where the outcome seems reasonably good.
PB02-23 A Study of Advanced Gallbladder Cancer to Evaluate Surgical Procedure and Poor Prognostic Factors
Keisuke Okamura, Japan

K. Okamura, T. Noji, Y. Nakanishi, K. Tanaka, T. Asano, T. Nakamura, T. Tsuchikawa, S. Hirano
Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Japan

Background: It is important to consider the selection of the suitable procedure and identification of poor prognostic factors in the treatment of gallbladder cancer (GBC).
Objective: This study was aimed to evaluate each operative procedure for GBC and to identify poor prognostic factors for advanced GBC after surgery.
Methods: We reviewed medical records of 53 patients without resection and 87 patients who underwent resection. All patients in the resection had subserosal or deeper invasion (advanced GBC). Overall survival curves and poor prognostic factors of advanced GBC in the radical resection were analyzed.
Results: Surgical procedures included partial liver resection with bile duct resection in 37 patients, major hepatectomy with bile duct resection in 30, hepatopancreatoduodenectomy (including minor hepatectomy) in 11, pancreatoduodenectomy in 10, and bile duct resection (including only cholecystectomy) in 19 patients. The R0 rate was 90% (78 patients). In total, 3 patients (3.8％) from the radical resection group died during hospital stay due to worsening of complications. In advanced GBC, the median survival time for radical resection was 26 months. It was significantly longer than the 3 months for the palliative resection and the 10 months for the non-resection (p< 0.0001 in both ). Pathological distant metastasis was the only independent prognostic factor based on univariate analysis (hazard ratio: 8.8, 95% C.I: -1.67～-0.41, p=0.0031).
Conclusion: Radical resection, according to preoperative imaging for advanced GBC, achieved high R0 resection rate. Developments of preoperative methods are expected to exclude patients with liver metastasis or para-aortic lymph node.
PB02-24 The Role of Pancreaticoduodenectomy in the Surgical Management of Gallbladder Carcinoma
Jun Sakata, Japan

J. Sakata, Y. Hirose, K. Yuza, K. Miura, T. Katada, K. Takizawa, H. Nagaro, 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 elucidate indications and limitations of pancreaticoduodenectomy (PD) for gallbladder carcinoma (GBC).
Methods: This study retrospectively analyzed the long-term outcomes of 37 patients undergoing PD for GBC. PD was indicated for tumors with evident peripancreatic nodal metastasis and/or massive invasion of the pancreas/duodenum/bile duct. Primary end point was overall survival (OS). The median follow-up time was 264 months.
Results: Morbidity (≥ Clavien-Dindo IIIB) and in-hospital mortality were 19% (n = 7) and 8% (n = 3), respectively. For all 37patients, OS following resection was 31% at 5 years and 25% at 10 years (median survival time, 20 months). Multivariate analysis identified residual tumor status (P = 0.009) and the extent of disease (P = 0.025) as independent prognostic factors. The 5-year OS in patients with and without residual tumor was 43% and 0%, respectively (P < 0.001). The 5-year OS in patients with peripancreatic nodal disease (n = 12), organ involvement other than the liver (n = 12), and the both (n = 13) was 52%, 37%, and 8%, respectively (P = 0.001). There were 10 5-year survivors; all the patients underwent R0 resection. Of the 10 patients, 6 had peripancreatic nodal disease; 3 had ≥ 3 positive nodes.
Conclusions: PD provides survival benefit for some patients with advanced GBC only if R0 resection is feasible. Patients with both peripancreatic nodal disease and organ involvement other than the liver are not good candidates for PD. PD may be beneficial in selected patients with peripancreatic nodal disease.
PB02-25 An Unusual Case of Choledochal Cyst Coexisting with Gallbladder Cancer
Vivek Kaje, India

V. Kaje1, H. B2, V. M3, R. Shetty3, R. Fernandes2, P. S2
1Surgical Gastroenterology, Yenepoya Medical College, India, 2General Surgery, Yenepoya Medical College, India, 3Surgical Oncology, Yenepoya Medical College, India

Introduction: Choledochal Cyst is a rare condition. Even rarer is a choledochal cyst in association with a gallbladder carcinoma.
Aim: Report an unusual case of choledochal cyst coexisting with gallbladder Cancer.
Case Details: A 49 years old male with no comorbidities presented with vague upper abdominal pain for 1 month. Clinical examination was normal. On evaluating with blood investigations including complete hemogram, LFT, USG abdomen with CECT abdomen and MRCP, it was diagnosed as type IC choledochal cyst with cancer gallbladder (fundal region). He underwent staging laparoscopy followed by open radical cholecystectomy with choledochal cyst excision and Roux en y hepaticojejunostomy. In the postoperative period he had bile leak which settled by itself on POD 8. Histopathology report revealed adenocarcinomaT3N0M0 with 0/17 lymphnodes were involved. Postoperatively he has received gemcitabine chemotherapy.
Conclusion: Choledochal cyst with gallbladder cancer is a rare condition, early detection and radical surgery is the only hope for prolonged survival.
PB02-30 A Study for the Expression of FAM83H, ZNF16, and FAM83H-related Proteins in Gallbladder Cancer
Jae Do Yang, Korea, Republic of

J.D. Yang1, S.W. Ahn1, H.C. Yu1, S.E. Hwang2
1Surgery, Chonbuk National University Hospital, Korea, Republic of, 2Daesion Sun Honspital, Korea, Republic of

Introduction: FAM83H is mostly known for its role in amelogenesis, however, recent reports suggest FAM83H might be involved in tumorigenesis. A search of the public database shows a significant association between FAM83H and ZNF16 in various carcinomas including biliary tract cancer. Although the studies of FAM83H in gallbladder cancer are limited, we inferred gallbladder cancer has similar traits with other biliary cancers.
Methods: We evaluated the clinicopathological significance of the immunohistochemical expression of FAM83H and ZNF16 in 105 gallbladder cancer patients.
Results: The expression of FAM83H and ZNF16 were significantly associated with each other. In univariate analysis, individual, and co-expression pattern of FAM83H and ZNF16 was significantly associated with shorter overall survival (OS) and relapse-free survival (RFS) of gallbladder cancer patients: nuclear expression of FAM83H (OS; P < 0.001,), cytoplasmic expression of FAM83H (OS; P < 0.00), nuclear expression of ZNF16 (OS; P < 0.001), cytoplasmic expression of ZNF16 (OS; P = 0.032). In multivariate analysis, nuclear expression of FAM83H (OS; P < 0.001) and the co-expression pattern of nuclear FAM83H and ZNF16 (OS; P < 0.001) were independent indicators of shorter survival of gallbladder patients.
Conclusion: These results suggest that FAM83H and ZNF16 might be involved in the progression of GB cancer, and their expression might be used as novel progression indicator for GB cancer patients.
PB02-32 Prediction of Malignancy Using Skin Autofluorescence in Patients with Gallbladder Carcinoma
Marcin Morawski, Poland

M. Morawski, M. Krasnodębski, M. Grąt, J. Borkowski, P. Krawczyk, J. Stypułkowski, A. Zhylko, W. Figiel, K. Zieniewicz
Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Poland

Introduction: Increased accumulation of advanced glycation end products (AGEs) may correlate with progression of numerous diseases, including some cancers. Skin autofluorescence (SAF) measurement in a non-invasive test that quantifies tissue AGEs. The aim of this study was to assess utility of SAF in prediction of malignancy in patients with gallbladder carcinoma (GBC).
Methods: This prospective study comprised 29 patients (7 men and 22 women) with suspected or confirmed GBC who underwent surgery in the Department of General, Transplant and Liver Surgery of the Medical University of Warsaw between September 2018 and November 2019. SAF was based on 3 separate preoperative measurements on the anterior side of the forearm and expressed in arbitrary units (AU). Data on patients' weight, height, BMI, and diabetes were collected preoperatively.
Results: Gallbladder carcinoma was diagnosed in 22 out of 29 patients (75.86%). Median SAF was 2.2 AU (IQR = 1.925 - 2.675) and 2.2 AU (IQR = 1.8 - 2.5) in GBC patients and individuals without cancer, respectively. There was no difference in SAF between patients with GBC and individuals without cancer (p=0.700). The lack of significant difference was unmodified by patient sex, presence of diabetes or BMI>25 (p=0.662, p=0.643, and p=0.629, respectively).
Conclusions: Although SAF may have predictive value in some cancers, this study does not provide evidence for increased accumulation of AGEs in patients with GBC.
PB02-33 Incidence of Inter Aortocaval Lymph Node Positivity in Early Gall Bladder Carcinoma
Smita Chauhan, India

S. Chauhan, S. Jha, S. Masood, A. Panday
Surgical Gastroenterology, Ram Manohar Lohia Institute of Medical Sciences, India

Introduction: Inter aortocaval (IAC) lymph node involvement in Gallbladder cancer (GBC) is considered metastatic (M1) disease . This study aimed to evaluate the incidence of IAC positivity in early GBC (T1/2 lesions), deemed resectable on pre-operative imaging.
Methods: A retrospective analysis of patients with suspected GBC, was undertaken, from a prospectively maintained data base, between Jan 2013 to July 2019. All patients deemed resectable on preoperative evaluation underwent staging laparoscopy followed by IAC sampling. During these procedures if no metastasis was evident, resection with R0 intent was attempted. Data was analysed using SPSS version16 and Chi square test for significance applied.
Results: Of 245 suspected GBC patients, 105 (42.8%) were deemed operable on preoperative imaging. Nineteen of these were found to have Xanthogranulomatous cholecystitis on final histopathology hence excluded from the analysis. Of the remaining 86 patients, 27 were found to have disseminated disease on staging laparoscopy/laparotomy of which 13 (15.1%) had IAC lymph node positive for malignancy on sampling. Incidence of IAC involvement in GBC cases taken up for surgery was 15.1%. One of the thirteen (7.6%) IAC lymph node positive patients had T2 lesion (T1+T2=33) while twelve (92.3%) were T3+T4(53) tumours.Thus incidence of IAC lymph node metastasis in early GBC was one in thirty three cases that is 3% (p< 0.014).
Conclusions: Gall bladder cancer, even if confined within the gallbladder, has a significantly high incidence of metastasis to interaortocaval lymph nodes which in turn upstages the disease from potentially resectable to metastatic.
PB02-34 Technical Feasibility and Surgical Outcomes of Modified Right Hepatectomy in Patients with Gall Bladder Neck Cancer with Jaundice : A Study of 22 Patients
Ram Daga, India

R. Daga, N. Jangir, L. Yadav, R. Rao, S. Gupta, G. Chauhan
Surgical Gastroenterology, SMS Medical College, India

Introduction: Patients with Gall Bladder Neck Cancer with jaundice are difficult to manage and have high mortality. We operated these patients with Right Hepatectomy, Resection of Seg IVb of Liver, resection of extrahepatic biliary tree and regional lymphadenectomy (Modified Right Hepatectomy). We evaluated Perioperative results and surgical outcomes in these patients.
Method: Retrospective analysis of Prospective database of patient with Modified Right Hepatectomy for Gall Blader neck cancer with jaundice in term of perioperative complications and survival outcomes was done
Results: Between January 2013 and December 2018, After preoperative imaging and evaluation 49 patients were planned for Modified Right Hepatectomy. All patients underwent Staging Laparoscopy, out of which 12 patients had metastatic disease. 15 patients had locally advance disease (bulky lymph nodes, Tumor extension to left duct), so surgery was deferred. Modified Right Hepatectomy was completed in 22 patients (17 Females, 5 Males). There was no perioperative mortality. Surgical Site Infection was the most common complication (4 patients, 18.2 %). Grade A Post Hepatectomy Liver Failure and Bile leak were othe important complication seen in 2 patients (9.1%) each. One year survival in 19 patients was 84.2%(16 patients). 3 years survival in 12 patients was 25% (3 patients)
Conclusions: In selected Gall Bladder Neck cancer patients with Jaundice Modified Right Hepatectomy can be performed with minimal morbidity and have reasonable survival benefits.
PB02-36 Meso-hepatectomy in a Locally Advanced Carcinoma Gallbladder in 21st Century: Is it Justified?
Soumen Roy, India

S. Roy1, S. Paikaray2, S. Mohanty3, M. Bhoi4
1Department of GI-HPB Surgery, AMRl Hospital, India, 2Medical Oncology, Bluewheel Hospital, India, 3Department of GI SURGERY, AMRl Hospital, India, 4Pathology, Bluewheel Hospital, India

Introduction: Based on the 2017 systematic review and meta-analysis meso-hepatectomy appears to be safe and comparable in both peri-operative and long term outcomes while comparing patients undergoing extended hepatectomy. Majority included hepatocellular carcinomas(>95%), cholangiocarcinomas but none have carcinoma(ca) gallbladder(gb). Right extended hepatectomy after biliary drainage and portal vein embolisation is the treatment modality for advanced ca gb. It is common in low socioeconomic strata of India(South Asia). Majority(90%) of them don't achieve R0 resection due to disease progression and procedural complications. Chemotherapy can't be given unless bilirubin< 5. The main difference between cholangiocarcinoma and ca gb is that cholangiocarcinoma spreads along ducts but ca gb infiltrates locallly. Hence meso-hepatectomy is not an inferior oncologic surgery in advanced ca gb.
Methods: 30 year old male presented with jaundice, weight loss. Scan showed gall bladder mass with hilar block and right hepatic artery(RHA) involvement. Maximum bilirubin was 24. He underwent biliary drainage and bilirubin came down to 14. Ultrasound doppler showed RHA block with good intra-hepatic flow. He underwent meso-hepatectomy with RHA excision and hepaticojejunostomy to right posterior sectoral duct and left duct. Blood loss was 1 litre with a duration of 10 hour. Post operatively neither there was liver failure nor bile leak. Histopathology report was T4N2Mx(ductal margins negative). He completed adjuvant chemotherapy and on follow up of 18 months found to have segment 6 metastasis and still on chemotherapy without jaundice.
Conclusion: Meso-hepatectomy is a safer onco-surgical alternative to extended hepatectomy in selected cases of advanced gall bladder cancers.
PB02-37 Rare Presentation of the Type I Choledochal Cyst in a Young Adult
Neelendra Yesaswy Muppalla, India

N.Y. Muppalla1, S. Sankar2
1GI Surgery, Sri Ramachandra Medical College and Research Institute, India, 2Sri Ramachandra Medical College and Research institute, India

Introduction: Incidence of malignancy in choledochal cyst is 7.5%. Most Common malignancy is cholangiocarcinoma (70%), Gall bladder adenocarcinoma (20%), rest others. It is more common in females, and as the age increases the incidence of malignancy increases, the mean age of presentation is 32 years. Although Type I choledochal cysts are more common, the incidence of malignancy is higher in type IV choledochal cysts. Japanese and Koreans have seen High Incidence of Gall bladder cancer in Pancreatico biliary maljuction(PBM).
Case report: We present a rare primary presentation of choledochal cyst in 34yrs/male who presented with complaints of vague right upper quadrant Pain for 4 months. On further evaluation with imaging studies he was diagnosed to have Type I Choledochal cyst with Gall bladder malignancy along with pancreatico biliary maljunction. Patient underwent Radical cholecystectomy with cyst excision and hepaticojejunostomy.
Conclusion: Adult Choledochal cyst presentation is usually in form of complication - Cystolithiasis, Infection, Pancreatitis, portal HTN, biliary cirrhosis, and malignancy. Mere Primary presentation of GB cancer along with Choledochal Cyst is quite unusual. We present this case as it is quite rare presentation.