Poster
Biliary 		  
PB05 Biliary: Technical Surgery (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PB05-01 Redo Surgery in Recurrent Biliary Cystadenocarcinoma at Common Bile Duct: A Case Report and Literature Review
Unenbat Gurbadam, Mongolia

U. Gurbadam1, Y. Amankyeldi1, A. Bold-Erdene2, J. Nyamsambuu3, C. Jigjidsuren1
1Hepato-Pancreato-Biliary Surgery, National Cancer Center of Mongolia, Mongolia, 2Pathology Department, National Cancer Center of Mongolia, Mongolia, 3Radiology, Medportal Hospital, Mongolia

Biliary cystadenocarcinoma is a very rare cystic tumor that arises in the liver or, less frequently, in the extra hepatic biliary system. It has been shown to arise in congenital liver cysts, bile ducts, biliary cystadenoma. There are few literature on recurrence of biliary cystadenocarcinoma at common bile duct after a complete resection by major hepatectomy previously. Therefore we report a case of recurrent biliary cystadenocarcinoma in a 65-year-old woman treated by re-surgery after four years since the first operation left hepatectomy followed by six course of chemotherapy.
Previously in 2014, we performed a left hepatectomy by glissonean approach for left portal pedicle. Patient discharged at POD#8 without complication. After the 4th year of follow-up, tumor recurred aggressively CA 19-9 was 347U/ml. Tumor was at whole proximal CBD and dilation of anterior and posterior bile ducts by CT. Distal CBD was free. The MRCP showed a solid mass in the CBD portion with partial obstruction of CBD, and takes only proximal CBD, T.Bil level was 35. We performed a resection of CBD and hepatojejunostomy. The surgery, post-operative course was uneventful. Surgical specimen shows yellow-brownish multilocular cystic lesions with mucinous fluid contents of 6x3cm. Histology shows a cystic neoplasm forming papillary projections, covered by an atypical mucin-producing glandular epithelium. The tumor was determined as well differentiated biliary cystadenocarcinoma.
We report here a rare case of re-surgery on recurrent biliary cystadenocarcinoma in extra hepatic biliary tract. Since the naturally low malignant cystadenocarcinomas are less invasive on surrounding vessels and tissues during re-surgery.
PB05-04 Comparison of Curative Effect between Nasobiliary Drainage and Biliary Stenting in Malignant Biliary Obstruction: A Systematic Review and Meta-Analysis
Wei Zhang, China

W. Zhang1, Z. Wei2, X. Che1
1Department of Pancreatic and Gastric Surgery, National Cancer Center/National Clinical Research Center for Cancer / Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China, 2Department of Hepatobiliary and Pancreatic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital & Shenzhen Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China

Background: To compare the efficacy of endoscopic nasobiliary drainage (ENBD) and endoscopic biliary stenting (EBS) in preoperative biliary drainage (PBD).
Methods: ENBD and EBS related literature of patients with malignant biliary obstruction published before September 2019 were collected from PubMed, EMBASE, and Cochrane Library for comparison analysis. Revman 5.3 statistical software was used for analysis.
Results: Nine studies were used for our comparative study. A total of 1435 patients were included, which consisted of 813 in the ENBD group and 622 in the EBS group. Meta-analysis showed that patients with malignant biliary obstruction who received ENBD had reductions in the rates of preoperative cholangitis (RR  =  0.44, 95% CI  =  0.34-0.58, P  <  0.00001), preoperative pancreatitis (RR = 0.69, 95% CI = 0.50-0.95, P =0.02), stent dysfunction (RR = 0.58, 95% CI = 0.43-0.80,
P =0.0008), morbidity (RR = 0.77, 95% CI = 0.64-0.93, P = 0.007) and postoperative pancreatic fistula (RR = 0.65, 95% CI = 0.45-0.92, P = 0.02) compared with patients who received EBS.
Conclusions: The rates of preoperative cholangitis, preoperative pancreatitis, post-operative pancreatic fistula, stent dysfunction, and morbidity of ENBD patients were lower than those of EBS patients. In clinical practice, the physical condition of each patient and their tolerance should be fully considered. ENBD should be given priority. EBS should be replaced if stent dysfunction or intolerance occurs.
PB05-05 Balloon-Assisted Stone Extraction (BASE): An Innovative Method for Lithotripsy during Laparoscopic CBD Exploration
Kwangyeol Paik, Korea, Republic of

K. Paik, J.S. Oh, E.K. Kim
The Catholic University of Korea College of Medicine, Korea, Republic of

Background: Balloon-assisted stone extraction (BASE) can be applied to remove the common bile duct (CBD) stones during laparoscopic CBD exploration (LCBDE).
Aim: This study aimed to analyze the efficacy of BASE.
Methods: A retrospective analysis of patients with CBD stone who underwent LCBDE using BASE at our center from 2001 to 2017, was conducted. The outcomes of BASE and potential factor for failure of this technique were also evaluated.
Results: A total of 163 patients underwent LCBDE using BASE for CBD stone were enrolled. Success rate of BASE was 88.3% (144/163) and 19 (11.7%) patients with failed BASE underwent Basket for lithotripsy additionally. The reason for aborting BASE were stone impaction (n=6), small stone (n=4), migration into IHD (n=3), and others (n=6). The overall success rate of stone clearance was 97.5% (159/163). The mean CBD diameter was 15.8 mm (range 7-34 mm), and the largest stone size was 13.8 mm (range 3-36 mm). 22 patients had undergone gastrectomy prior to LCBDE. The overall complication rate was 4.9% (8/163), including bile leakage in 2 patients (1.2%), bleeding in 2 patients (1.2%) and pancreatitis in 4 patients (2.4%). There was no procedure related complication.
Conclusions: BASE for CBD stone is safe and effective techniques for the treatment of CBD stones.
PB05-07 Choledocoduodenostomy: Technique of Lateral Side to Side Anastomosis
Shahidur Rahman, Bangladesh

S. Rahman1,2,3
1Bangobandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, 2Hepatobiliary Pancreatic and Liver Transplant, Liver Gastric Specialized Hospital, Dhaka, Bangladesh, 3Hepatobiliary Pancreatic and Liver Transplant, Panpacific Hospital, Dhaka, Bangladesh

Introduction: Development of new technique in the anastomosis between first part of duodenum and distal end of common bile duct. Efficacy established in the study.
Materials and method: A prospective study, period since 2003 till today. About 494 cases operated by this technique. Done in the cases where obstructive jaundice developed in the distal end of common bile duct by stones ,benign strictures,malignant lesion. Stones of common bile duct removed by endoscopic papillotomy and dormia basket.Some cases procedure failed to clear the stones from common bile duct, because of lithogenic bile repeated stones formed causing obstruction,after papillotomy some cases further development of stricture, in old and debilitated patient with malignant lesion at distal CBD where major surgical intervention harmful to life. Different investigation like liver function test, cancer marker , Radiological investigations ultrasonography, CT scan ,MRCP performed for the diagnosis.
Technique of anastomosis: This ensure intraoperatively a hermetic "bile-proof" anastomosis 2-cm-longitudinal incision made in supraduodenal part of common bile duct mark as lower end B1,upper end B2 and an adjacent vertical incision made in first part of the duodenum mark D1 for upper end and D2 for lower end. First sutures placed between B1 and D1 on right side, second suture on left side of both incision.Used 3-0 vicryl,continuous stitches.Start below to up upto B2 where D2 meet at same point.Right wall and left wall anastomosis compleated. The patient recovered uneventfully, had no complaints of abdominal pain fever.
Conclusions: Procedure technically simple and safe, results no tension of anastomosis.Not mobilize duodenum.
PB05-08 Quincke's Triad Post-percutaneous Transhepatic Biliary Drainage Insertion: A Case of Delayed Haemobilia
Zamri Zuhdi, Malaysia

A. Zainal Mokhtar, C. Ian, A. Azman, Z. Zuhdi
UKM Medical Centre, Malaysia

Introduction: Percutaneous transhepatic biliary drainage (PTBD) is a common procedure done in hepatobiliary centre for biliary obstruction or leak. Complications of PTBD range from minor complication such as access port discomfort to a major one which is death1. Bleeding post PTBD is not uncommon. This a case of upper gastrointestinal bleeding of a patient with history of PTBD insertion who presented to us more than one month post procedure.
Case report: A 58-years-old man presented with UGIT bleed 1 month prior to PTBD insertion, however OGDS and colonoscopy was normal. He had a history of subtotal gastrectomy with roux-en-Y reconstruction in 2010 for pyloric adenocarcinoma. PTBD was inserted because he presented with cholangitis secondary to distal common bile duct stricture during previous admission.
Due to current problem, Computed tomography (CT) angiography was performed, however no evidence of acute arterial haemorrhage either from the biliary tree or from the bowel.
Subsequently hepatic artery angiogram was done as he has another episode of haematemesis. In this study, there was active contrast extravasation into biliary system in keeping with arteriobiliary fistula. The bleeding was successfully controlled after superselective embolization was performed. At the same time, balloon plasty of CBD stricture was performed and Fogarty catheter was used to dislodge blood clots in CBD.
Conclusion: Haemobilia is a potentially fatal complication of PTBD and should be considered as one of the cause of gastrointestinal bleeding in patients with unidentified source. Interventional radiology provides effective and save method for the treatment of arteribiliary fistula.
PB05-09 Safety of Barbed Suture Material for Wound Closure in Single Incisional Cholecystectomy
Sung Yub Jeong, Korea, Republic of

S.Y. Jeong, S.H. Choi, Y.S. Kim
Division of Hepatobiliary and Pancreas, Department of Surgery, Bundang CHA Medical Center, Korea, Republic of

Single incisional cholecystectomy is surgical methods that provide comparable results to standard laparoscopic cholecystectomy (LC). However, single incisional cholecystectomy has been accused for post-operative incisional hernia. The incidence of incisional hernia after single incisional cholecystectomy is reported about 2.4% in short-term follow-up studies and up to 10.9% in long-term follow-up. One of incisional hernia's risk factor is surgical technique failure during wound closure.
This study evaluated the incidence of patients developing incisional hernia after single incisional cholecystectomy, and we hope to suggest a solution in overcoming incisional hernia arising out surgical technique failure by using barbed suture material during wound closure.
Total number of 984 patients underwent single incisional cholecystectomy between March 2014 and December 2019. During this period, there were 689 patients who underwent wound closure with non-barbed suture material and 295 patients with barbed suture material. Both Patient groups were comparable in age, gender, BMI and operation time. 2 patients developed incisional hernia in non-barbed suture group and none in the barbed suture group. The incidence of incisional hernia was higher in the non-barbed suture group, but statistically insignificant. (p=1.00)
Our large volume study showed lower incidence of incisional hernia to comparing previous studies. Also, there was no incisional hernia patient in barbed suture group, although statistically insignificant, which means possibility of overcoming the surgical technique failure using barbed suture material. We hope to share our experience on safety and advantage of using barbed suture in wound closure leading to a decrease in the incidence of incisional hernia.
PB05-10 Single-incision Laparoscopic Cholecystectomy: A New Classification for Shape of the Navel and Modification of the Method for Incisions in the Umbilical Region
Manabu Watanabe, Japan

M. Watanabe, K. Asai, M. Kujiraoka, H. Moriyama, R. Watanabe, T. Enomoto, N. Futawatari, T. Kiribayashi, Y. Saida
Surgery, Toho University Ohashi Medical Center, Japan

Single-incision laparoscopic cholecystectomy (SIL-C) is a surgical procedure that emphasizes esthetic outcomes. The method used for making the incision in the umbilical region, as the sole wound site, is of the utmost importance, not only because it determines the esthetic outcome, which is a merit of SIL-C, but also because it greatly influences the operability of the forceps. In SIL-C, making a large incision is important to reduce restrictions on procedures resulting from interference between forceps. However, because vertical incisions involve large incisions, the incision line may deviate from the navel and result in poor esthetic outcomes. Therefore, in the pursuit of both favorable esthetic outcomes and safety, we developed a new classification system for the shape of the umbilical region, and have been performing incisions according to these classifications. Specifically, the shape of the navel was classified into the following six types: vertical; horizontal; T-shaped; inverted T-shaped; round with shallow depression; and protruding. In addition, we are performing the following types of incisions according to the shape of the umbilical region, to prevent deviation of the incision line from the umbilical region: vertical; horizontal; T-shaped; inverted T-shaped; and S-shaped. By performing incisions that match the shape of the umbilical region in this manner, a large incision can be made without affecting the esthetic outcomes, thereby promoting the operability of forceps and ensuring both favorable esthetic outcomes and safety.
PB05-11 Comparison of Crush Clamp Method and Ultrasound Dissection in Liver Transection Outcomes
Amin Bahreini, Iran, Islamic Republic of

A. Bahreini1, K. Kazemnia2
1Hepatobilliary, Ahvaz Jondishapoor, Iran, Islamic Republic of, 2General Surgery, Jondishapoor Ahvaz, Iran, Islamic Republic of

Background: Preoperative hemorrhage and postoperative bile leakage are important complications of hepatectomy. various methods to reduce intraoperative bleeding during liver transection have been reported. We designed a randomized clinical trial to compare crush clamp method and ultrasound dissection in liver transection.
Method: Twenty patient experienced hepatectomy with the crush clamp method.
The ultrasonic dissection group consisted of twenty patient.
The surgical outcomes including:
Operation duration,bleeding ,p.c request,bile leakage,hospital stay duration and hepatic failure are evaluated and compared.
Results: Mean blood loss was 247 cc in crush clamp group and 232 cc in ultrasonic dissection group.
Blood loss in ultrasonic method was lower but the difference did not raech significant level.
Duration of surgery was almost identical .but duration of transection in crush clamp group was shorter than ultrasonic dissection group.
That mean the crush clamp method is faster.
Acidosis and hepatic failure were rare and difference was not significant.
There were not cases with infection and bile leakage.
Conclusion: Post operative complications did not differ in two groups.but duration of transection in crush clamp was shorter than ultrasonic dissection method .and blood loss was almost identical .beacuse ultrasonic dissection is an equipment dependent procedure and more expensive therefore we trend to perform liver transection with crush clamp method.
PB05-12 Robotic Single Site Plus One Port: Choledochal Cyst Excision
Jae Uk Chong, Korea, Republic of

J.U. Chong, J.H. Lee, H.S. Lee, K.H. Kwon
Surgery, National Health Insurance Service Ilsan Hospital, Korea, Republic of

Introduction: Choledochal cysts in adults are rare and the treatment requires complete excision of the cyst with bilio-enteric reconstruction. Here, we present three cases of robotic single site plus one port choledochal cyst excision with roux-en-Y hepaticojejunostomy.
Methods: Choledochal cyst excision was performed using the Da Vinci single-site surgical platform (DVSSP) with one additional port. Additional robotic 12mm-port was placed on right anterior axillary line, along the level of DVSSP. Choledochal cyst was meticulously separated and dissected from the level of hepatic hilum to intrapancreatic common bile duct and distal part of the cyst was ligated with hemo-loc clips then divided. After transecting proximal part of the cyst at the level of hilum, roux-en-Y hepaticojejunostomy was performed intracorporeally in a retrocolic manner. Drain was inserted at the additional port site and specimen was delivered through umbilicus.
Results: The mean age of 3 patients was 53 ± 6 years old. Two patients were female and diagnosed with type I choledochal cyst. One patient was a male diagnosed with type IVa choledochal cyst. Mean cyst size was 6.2 x 3.8cm. Mean total operation time was 475 ± 41 minutes. Mean postoperative length of stay at the hospital was 9 ± 3 days. One case of pancreatitis and one case of bile leakage occurred. Both cases were resolved with conservative care.
Conclusion: Robotic single site plus one port choledochal cyst excision seems feasible and safe with better anatomic visualization and increased dexterity for bilio-enteric reconstruction..
PB05-13 Hepatopancreatoduodenectomy for Biliary Cancer - Are the Outcomes Acceptable?-
Takefumi Niguma, Japan

T. Niguma, T. Kojima, T. Fuji, H. Miyake, T. Mimura
Surgery, Okayamasaiseikai General Hospital, Japan

Background: Hepatopancreatoduodenectomy (HPD) is usually indicated for advanced biliary cancer. Operative resection is the only way to cure for the advanced biliary cancer patients. However HPD is infrequently performed widely because of high morbidity and mortality. The aim of this retrospective study was to clarify the impact of resected liver volume on outcomes of HPD.
Methods: Between January, 1999 to December, 2019, 302 biliary cancer patients underwent bile duct resection with hepatectomy (HBD; n=108) or pancreatoduodenectomy (PD; n=160), or HPD (n=34). Liver resection was categorized right lobe resection (R; including left trisegmentectomy), left lobe resection (L), and minor liver resection (M; e.g. S4aS5).
Results: Sever morbidity (Clavien grade 3B or over) and mortality of R-HPD, L-HPD, and M-HPD were 27%, 0%, 6% and 9%, 0%, 0% respectively. Those of R-HBD, L-HBD and M-HBD were 13%, 7%, 9% and 13%, 2%, 0% respectively. Those of PD was 7% and 0.6%. Pancreatic fistula (PF) rate (ISGPF grade B or C) of R-HPD, L-HPD, and M-HPD was 30%, 57%, 40% respectively, and that of PD was 31%.
Conclusion: HPD limited to left lobe or minor liver resection is safe and feasible operation. In our series, the mortality of HPD and HBD was similar, and it was mostly occurred after R. In contrast, PF rate seems to be not correlated to resected liver volume. Preserving the liver function is the top priority for R-HPD.
PB05-14 Technical Pitfalls and Complications after Vascular Resection for Advanced Hilar Cholangiocarcinoma
Ruslan Alikhanov, Russian Federation

R. Alikhanov, M. Efanov, I. Kazakov, A. Vankovich, A. Koroleva, D. Pavlenko, N. Elizarova, N. Kulikova, A. Petrin
Department of HPB Surgery, Moscow Clinical Scientific Center, Russian Federation

Background: Technical pItfalls and complications of vascular resection (VR) for treatment of hilar cholangiocarcinoma (HCh) play an important role in outcome but not completely described in the literature. The aim of this study was the analysis of technical aspects of VR that may cause serious complications in single hpb surgery department.
Patients and methods: Within five years (January 2015 to December 2019), 107 consecutive patients with HCh underwent radical surgery with curative intent in Moscow Clinical Scientific Center. Resection and reconstruction of the portal vein and hepatic artery was performed if necessary for a complete removal of the tumour. Different types of portal vein and hepatic artery reconstruction analyzed and complications assessed.
Results: We performed 14 arterials and 26 portal vein reconstruction. Cancer-free margins achieved in 80%. The perioperative morbidity and mortality rates of this cohort were 60,2% and 10.7%, respectively. Technical pitfalls includes: hepatoduodenal inflammation due to severe cholangitis, left hepatectomy, significant gap among arteries or veins. Management of cholangitis before liver resection, modifying technique of vascular reconstruction to prevent using inflamed vessels not mobilisation of remnant liver may decrease the risk of vascular complications.
Conclusions: Radical liver resection combined with vascular reconstruction provides acceptable morbidity and mortality for treatment of HC. Technical pitfalls of vascular resection should be taken into account as an important factor of surgical outcome.
PB05-15 Outcome of Laparoscopic Cholecystectomy by Exposing the Inner Layer of the Subserosal Layer
Nattawut Keeratibharat, Thailand

N. Keeratibharat1, J. Chansangrat2
1School of Surgery, Institute of Medicine, Suranaree University of Technology, Thailand, 2School of Radiology, Institute of Medicine, Suranaree University of Technology, Thailand

Introduction: Bile duct injury is the serious complication of laparoscopic cholecystectomy (LC). Therefore, the critical view of safety has been accepted as a safe method for gaining a sufficient view of Calot's triangle. However, it usually difficult to achieve a critical view of safety in presence of severe gallbladder inflammation due to a frozen Calot's triangle. Universal safe procedure of laparoscopic cholecystectomy by exposing the inner layer of the subserosal(SS) layer was introduced by G.Honda et al (2016). This approach was used for many cases with cholecystitis with severe inflamed gallbladders in our institution. The purpose of this study was to evaluated outcomes of LC that performed by exposing the inner layer of the serosal layer.
Methods: Demographic data and peri-operative data were recorded for both emergent and elective LCretrospectively. The procedure was done by dissecting the gallbladder along the SS-inner layer to achieve cystic duct. The outcome of procedures were recorded.
Result: Fifty patients who underwent laparoscopic cholecystectomy in which technique was used. In all cases, the procedure was complete without complications. The mean operating time was 62 minutes (range 30-110 minutes) and the mean of blood loss was 22.6 ml (range 2-100 ml).
Discussion: Applying this standardized procedure, we have safely performed LC in all cases without intraoperative cholangiography. But we considered that exposing the ss-inner layer without of gallbladder perforation more easily in case of acute cholecystitis because the ss-inner layer had become frozen by fibrotic change.
PB05-17 Curative Hepatectomy for Todani Type IV-A Biliary Dilatation(BD) in Adults: Removal of Cystic Dilatation and Biliary Stricture
Xiaobin Feng, China

J. Dong1,2, S. Yang1, B. Liu3, Q. Lu1, S.-Q. Yu1, H.-T. Xia3, J.-P. Zeng1, C.-H. Xiang1, X. Feng1
1Beijing Tsinghua Changgung Hospital, China, 2Tsinghua University, China, 3Hospital of Hepatobiliary Surgery, Chinese PLA General Hospital, China

Introduction: There is no universal surgical strategy for patients with Todani type IV-A BD. Traditionally, excision of the extrahepatic cyst with hepaticojejunostomy is the standard procedure, but long-term outcome is not satisfactory. This study aimed to analyze postoperative and long-term outcomes of a consecutive series of patients undergoing curative hepatectomy for Todani type IV-A BD.
Patients and method: All patients who underwent hepatectomy for Todani type IV-A BD in adults during 2007 to 2017 were retrospective analyzed at high-volume centers. Patients were divided into two groups, A: re-operation group who had previous surgery, B: operation group who received initial surgical treatment. Two principles were used in this study. One is radical but conservative hepatectomy and the other type of surgery was based on the anatomical level of diseased bile duct. Segmental BD was removed by anatomical hepatectomy.
Results: There were 117 patients enrolled，66 in group A and 51 in group B. Hepatectomy was performed in 63 and 43 patients in group A and B, respectively. Local BD excision in hepatic hilum was performed in 3 and 8 patients (P = 0.084), while radical resection of cystic dilatation of intrahepatic bile ducts was achieved in 60 and 48 patients, respectively. Postoperative morbidity, but not mortality in group A，was significantly higher.
Conclusion: Based on the morphological feature and anatomical level of intrahepatic BD, the strategy of radical but conservative hepatectomy is safe and effective for the treatment of complex Todani type IV-A BD in adults.
PB05-18 Pancreas-sparing Partial Duodenectomy with Roux-en-Y Pancreatobiliary Reconstruction for Iatrogenic Duodenal Injury
Aleah Brubaker, United States

A. Brubaker1, L. Salamone2
1Abdominal Transplantation, Stanford University, United States, 2General Surgery / Surgical Oncology, Santa Clara Valley Medical Center, United States

Introduction: Injury to the second portion of the duodenum and ampulla of Vater is a highly morbid complication. We report successful management of iatrogenic perforation with a pancreas-sparing partial duodenectomy and duct-to-mucosa pancreatobiliary reconstruction.
Methods: A healthy 40 year old woman underwent laparoscopic right nephrectomy for xanthogranulomatous pyelonephritis. The inflammatory mass abutted the duodenum and two large duodenotomies resulted from cautery injury. The anterior and medial walls were extensively disrupted. A cholecystectomy was performed and a wire was advanced through the cystic duct to identify the ampulla. We confirmed that the ampullary mucosa was not salvageable. The antrum was divided and duodenum carefully separated from the pancreas head. The pancreatic and bile ducts were divided sharply. Duodenum was stapled proximal to the mesenteric vessels. A retrocolic Roux limb was delivered. Pancreas head was invaginated with an outer layer of permanent 3-0 suture. The 1 mm ducts were united with suture and 3.5 French feeding tubes secured as stents. Duct-to-mucosa anastomosis was completed with absorbable 6-0 monofilament suture. A gastrojejunostomy was completed distally.
Results: The patient had no post-operative complications. Drains were removed on post-operative day 8 after drain amylase studies were normal. She was discharged on post operative day 11.
Conclusions: Pancreas-sparing partial duodenectomy with Roux-en-Y reconstruction is a viable option to treat severe proximal duodenal injury or perforation. As an alternative to total duodenectomy, it may preserve the duodenum's roles in regulation of gastrointestinal hormone release and organization of gastric motor function.
[Duodenal injury and reconstruction]
PB05-19 Safety and Economics of Continuous and Interrupted Suture Hepaticojejunostomy - An Audit of 556 Surgeries
Nalini Kanta Ghosh, India

N.K. Ghosh, R. Saxena, R.K. Singh, A. Singh, R. Rai, S. Sharma, A. Kumar, A. Behari, V.K. Kapoor
Surgical Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, India

Background: Hepaticojejunostomy (HJ), a standard method of bilioenteric anastomosis, is done with interrupted sutures by most surgeons. This study compares the safety and economics of continuous (CSHJ) and interrupted suture hepaticojejunostomy (ISHJ).
Methods: A retrospective analysis of all HJ between January 2014 and December 2018. Patients with type IV or higher biliary injuries, duct diameter < 8 mm and/or associated vascular injury were excluded.Patient demographics, pre-operative parameters including diagnosis, intra operative parameters including type of suture, number of suture, suturing time, and postoperative morbidity (Clavien Dindo) were recorded. Mc Donald's Grade A and B were considered as good outcome. Cost of suture type (PDS-3-0/5-0 mean cost-INR 686/length, vicryl 3-0, 4-0 mean cost- INR 486/ length), suture length, operation theatre time (INR 5000/hour) were considered for comparison of economics of both techniques. Statistical analysis in SPSS 22.0 software.
Results: 556eligible patients were analysed. 468 patients underwent ISHJ and 88 patients underwent CSHJ. Figure 1 shows patient details.Monofilament sutures were preferred in continuous suturing. Demographic profile was comparable. ISHJ required significantly increased number of sutures, time and cost. Bile leak was significantly more in the ISHJ. 54 patients had bile leak (6 CSHJ and 48 ISHJ). One patient in each group had mortality due to septic shock. Four patients (3 ISHJand 1 CSHJ) required PCD insertion and two patients require single time aspiration. Morbidity was comparable. Follow up McDonald's Grade B was significantly higher in ISHJ.
Conclusion: CSHJ is safe, economic and worthy of routine practice.
[Patient Details]
PB05-20 Safe Cholecystectomy Using an Indocyanine Green(ICG) Fluorescence Cholangiography during Laparoscopic Cholecystectomy
Kee-Hwan Kim, Korea, Republic of

K.-H. Kim
Surgery, The Catholic University of Korea College of Medicine, Uijeongbu, Korea, Republic of

Introduction: Bile duct injuries are the most dismal complication in cholecystectomy. The Critical View of Safety (CVS) has been shown to be a good way to obtain the secure anatomical identification. We try to get an early detection of imaginatory dissection line (fig. 1.) for obtaining the CVS using an ICG fluorescence cholangiography during laparoscopic cholecystectomy
Method: Sixty six patients underwent laparoscopic cholecystectomy using ICG cholangiography. Thirty patient were grouped into two groups, with one group underwent needlescopic grasper assisted single incision laparoscopic cholecystectomy (nSLIC) (15 patients) and another group underwent Three port laparoscopic cholecystectomy (TPLC) (61 patients). The surgical outcome that was composed with early detection time and rate of imaginatory dissection line, critical view of safety (CVS) time, major procedure time and total operation time, and the postoperative complication was made.
Results: Total operation time(skin to skin) of TPLC was shorter than nSILC group (nSILC: 67.9 ± 24.1 min, TPLC: 45.0 ± 22.8 min, p = 0.007). We can't get visualization of biliary tree in five patients who was treated with ERCP. Imaginatory dissection line obtaining rate showed fifty six patients (56/61) in two groups. And, confirmatory dissection line obtained all patients in two groups (56/61).
Conclusions: ICG fluorescence cholangiography during laparoscopic cholecystectomy may get an early imaginary and confirmatory dissection line during laparoscopic cholecystectomy.
[Fig. 1. Imaginatory dissection line in ICG cholangiography during laparoscopic cholecystectomy]
PB05-21 Laparoscopic Cholecystectomy in Patients with Left Sided Gallbladder Using an Indocyanine Green (ICG) Fluorescence Cholangiography
Kee-Hwan Kim, Korea, Republic of

K.-H. Kim
Surgery, The Catholic University of Korea College of Medicine, Uijeongbu, Korea, Republic of

Introduction: Left-sided gallbladder is a relatively rare anatomical variation that is frequently associated with a biliary system anomaly. In patients with LSGB, LC is associated with a higher incidence of bile duct injury (4.4%), necessitating the establishment of a safe surgical approach in these patients. Here, we describe a case of left-sided gallbladder with cirrhotic liver treated by using an ICG fluorescence cholangiography during laparoscopic cholecystectomy.
Method & Results: 62-year-old man with gallbladder adenomyoma was admitted to our hospital. Computed tomography demonstrated that the gallbladder was centrally dislocated and left-sided gallbladder with right-sided ligamentum teres. A laparoscopic cholecystectomy was performed. The round ligament was attached to the right side of the gallbladder, and the left-sided gallbladder was diagnosed by intraoperative findings (figure 1.). The patient was discharged 2 days after surgery without postoperative complications.
Conclusions: ICG fluorescence cholangiography should be used in cases of left-sided gallbladder during laparoscopic cholecystectomy. An assessment of the extra- and intrahepatic biliary system is essential to avoid biliary injury in cases of left-sided gallbladder.
[Fig.1 Intraoperative photography in left sided gallbladder during laparoscopic cholecystectomy]
PB05-22 T-tube in Moderation: T-tube Drainage versus Primary Closure after Open Common Bile Duct Exploration for Common Bile Duct Stone: A Single Institution Experience
Romulo Ong Abrantes, Philippines

L.L. Limjoco1, J.G. Teh-Yap1, A. David2, R. Ong Abrantes2, K.D. Parilla1, A. Cañones1, R. Barroso1, R. Sarmiento1, E. Tan1
1Rizal Medical Center, Philippines, 2Surgery, Rizal Medical Center, Philippines

Introduction: To discuss and compare outcomes and complications of routine T-Tube placement versus primary closure in patients who underwent open common bile duct exploration for choledocholithiasis.
Methods: This is a randomized prospective analysis of 35 patients categorized as moderate to high risk for CBD stone who underwent open choledochotomy. Thirty (30) patients were included and were randomly divided into 2 groups: T-tube drainage (TD, n=20) and primary closure (PC, n=10). Morbidity was graded using the Clavien-Dindo (CD) classification.
Results: Patients in the TD group had less overall complications than patients in the PC group (20% vs 30%, respectively; p=0.083); however, the TD group had more severe (CD Grade III or higher) complications than the PC group (75% vs 0% respectively; p=0.052). Complications included two patients with bile leak for pulled t-tube, post-op biliary stricture and acute kidney injury which required dialysis. Most of the complications in the PC group (3/10, or 30%) were minor complications (CD 1 or 2). There was no mortality in both groups. All 30 patients were followed-up for 3-12 months, with a median follow-up time of 6 months.
Conclusion: There was no statistically significant difference between T-tube placement and primary closure in terms of morbidity and long-term outcomes. Primary closure of the choledochotomy after biliary exploration for common bile duct stones is a safe and feasible alternative to routine T-tube drainage in carefully selected cases.
PB05-23 Balloon Dilation and Triple Catheter Placement Technique for Treatment of Proximal Biliary Stenosis
Guillermo Angel Herrera-Chávez, Peru

G.A. Herrera-Chávez1, G. Araujo-Almeyda2, R.R. Cruzalegui-Gomez1, V.H. Torres-Cueva1, S. Alfaro-Ita2, C.M. Yeren-Paredes1, J.J. Nuñez Ju1, M.A. Fuentes-Rivera-Carmelo1
1Servicio de Cirugía de Hígado y Vías Biliares, Hospital Nacional Guillermo Almenara Irigoyen, Peru, 2Servicio de Radiología Intervencionista, Hospital Nacional Guillermo Almenara Irigoyen, Peru

Introduction: Post-surgical bile duct lesions occurred in approximately 0.5% of cholecystectomies and are associated with high mortality. These lesions include leaks, stenosis, removal of part of the duct and arterial injury. Percutaneous and endoscopic approaches can definitely treat biliary lesions.
Objective: To present the experience of a clinical case where percutaneous interventional treatment of a bile duct stenosis with cholangioplasty and placement of tutors was performed in a single time.
Methods: 79-year-old male with a history of high blood pressure, left cerebrovascular accident, open cholecystectomy 20 years ago and bile duct stenosis.
tomography with contrast that showed proximal extrahepatic bile duct stenosis Bismuth II. An endoscopic cholangiopancreatography is performed that identifies the bile duct stenosis and an attempt is made to place a stent while passing a guide, but the catheter device cannot be placed through the diameter of the stenosis. Interventional radiology performs a percutaneous cholangiophraphy identifying the stenosis and performs balloon expansion of the same and inserts a biliary silicone drain along with two 8 fr and 10 fr tutors handcrafted from multipurpose drainage catheters (Cook medical) in parallel at the level of stenosis (maximum diameter 20 Fr)
Outcome: patient presented a favorable evolution after the procedure, presented as a minor complication an acute renal injury that resolved with observation
Conclusion: Percutaneous treatment with balloon dilation and the use of tutors at the level of stenosis was safe and successful in our patient.
[Silicone tutors and biliary drain at the level of bile duct stenosis]
PB05-25 Oddi Sphincter Repair for Biliary Complications after Endoscopic Papillectomy
JP Zeng, China

J. Dong, J. Zeng, N. Jiang, S. Jin, S. Yu, C. Xiang
Department of Hepatobiliary Surgery, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, China

Introduction: Endoscopic papillectomy (EST) is widely used in the treatment of benign biliary diseases. However, EST can permanently disrupt the function of the Oddi sphincter, resulting in an increased risk of cholangitis, choledocholithiasis, and cholangiocarcinoma.
Methods: A novel surgical procedure was designed to repair disrupted sphincter Oddi. During the operation, the duodenum was cut on the anterior wall. 8F catheter was perforated through the duodenal nipple from the common bile duct. The injured sphincter was intermittently sutured until the size of the opening was equivalent to the diameter of the catheter. Then the anterior wall of the duodenum was sutured continuously. The drainage tube was placed in the common bile duct, and be removed 4 weeks after the operation.
Results: A total of 14 patients received the repair surgery. The primary diseases for EST were cholecystolithiasis combined with choledocholithiasis in 8 cases and hepatolithiasis combined with choledocholithiasis in 6 cases. In these 14 patients, four of them simultaneous underwent cholecystectomy, five of them underwent hepatectomy. Postoperative complications rate was 14.3%, including bile leakage (1 case), incision infection (1 case). The mean follow-up time was 39.5 months. One patient still had intermittent cholangitis due to severe biliary cirrhosis, and the other 13 had a good prognosis (92.8%).
Conclusion: As a safe and effective surgical method to reconstruct SO function, Oddi sphincter repair retains the normal physiological structure of the biliary tract, and is expected to be a solution to solve and prevent serious long-term complications after EST.