Poster
Biliary 		  
PB06 Biliary: Miscellaneous (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PB06-04 Metronomic Photodynamic Therapy Using an Implantable Electronic Device, a Preclinical Experiment for Introducing Phototherapy into Cancer Treatments in Internal Organs
Izumi Kirino, Japan

I. Kirino1,2, K. Yamagishi3, I. Takahashi4, H. Amano5, S. Takeoka4, T. Fujie6, S. Uemoto1, Y. Morimoto7
1Department of Surgery, Kyoto University, Japan, 2Department of Physiology, National Defense Medical Collage, Japan, 3Digital Manufacturing and Design Centre, Singapore University of Technology and Design, Singapore, 4Graduate School of Advanced Science and Engineering, Waseda University, Japan, 5Department of Pediatric Surgery, University of Tokyo, Japan, 6School of Life Science and Technology, Tokyo Institute of Technology, Japan, 7Physiology, National Defense Medical Collage, Japan

Introduction: In a modern aging society, people expect high-quality cancer treatment but don't want to impair their quality of life. These trends made us imagine the needs of a novel cancer treatment system. We intend to develop a less invasive, low-cost cancer treatment system by using an implantable electronic device and introducing photodynamic therapy (PDT) into the treatment of malignancies in internal organs, including HBP area.
Methods: We combined wirelessly powered fingernail-size LED chip, and tissue adhesive biomaterials to develop suture-free, tissue-adhesive, wirelessly powered LED devices. As a preclinical experiment, we investigated the anti-tumor effect of low-power and long-term photodynamic therapy, termed metronomic PDT, by using this device for the mouse cancer model. The device was implanted subcutaneously beneath intradermal tumors on the back of mice, and the mice could move freely in the cage placed on the antenna board that enables continuous illumination on the tumor. During the ten days of treatment, a photosensitizer (photofrin) was administered intravenously for two times.
Results: The mice receiving mPDT showed significant growth suppression of the tumor when compared to the control mice. There was no adverse reaction in the surrounding normal tissues of the treatment group. Also, this experiment showed the effectiveness of green light, which has yet to be used clinically in PDT for the treatment of solid tumors.
Conclusions: Metronomic PDT using implantable optoelectronic devices can be applied safely into the treatment of HBP malignancies as a low cost and less invasive local treatment method.
PB06-05 Bacterial Gastroenteritis and the Risk of Biliary Tract Cancer: A Population-Based Study
Elise de Savornin Lohman, Netherlands

E. de Savornin Lohman1, J. Duijster2,3, B. Groot Koerkamp4, L. Mughini Gras2,5, P. de Reuver1
1Surgery, Radboudumc, Netherlands, 2RIVM, Netherlands, 3LUMC, Netherlands, 4Surgery, Erasmus MC, Netherlands, 5Utrecht University, Netherlands

Background: Salmonella has shown to have oncogenic transformative effects and thereby increase the risk of certain cancers. For Campylobacter, no comparable effects have been demonstrated. Risk factor identification may allow for timely diagnosis and preventive treatment. To substantiate the oncogenic potential of Salmonella, this epidemiological study compared the incidence of extrahepatic biliary tract cancer (ehBTC) in patients with diagnosed Salmonella or Campylobacter infection with the ehBTC incidence in the general population.
Methods: National infectious diseases surveillance records for patients aged ≥20 years when diagnosed with Salmonella or Campylobacter infection during 1999-2016 in the Netherlands were linked to the Netherlands Cancer Registry. All infections were clinically severe infections confirmed by laboratory testing. Incidence of ehBTC in Salmonella and Campylobacter patients ≥1 year post-infection was compared to the incidence of ehBTC in the Dutch general population using Standardized Incidence Ratios (SIRs).
Results: 16.252 patients were diagnosed with Salmonella and 27.668 with Campylobacter infection. Of those, nine developed ehBTC at a median of 46 months (range 13-67) after Salmonella infection and seven at median 60 months (range 18-138) after Campylobacter infection. Compared to the general population, the SIR of ehBTC in Salmonella patients was 1.53 (95%CI 0.70-2.91). In patients aged < 60 years, SIR was 1.74 (95%CI 0.36-5.04). For Campylobacter patients, SIR was 0.97 (95%CI 0.39-2.00).
Conclusion: Although statistical significance was not reached, there was a tendency towards increased occurrence of ehBTC among salmonellosis patients, but not among campylobacteriosis patients. Further research is necessary to uncover putative oncogenic transformative effects of other enteropathogens.
 Observed incidenceExpected incidenceSIR95% CIP-value
Salmonella, all patients95.881.530.70-2.910.280
20-6031.741.720.36-5.040.507
Male52.6651.880.61-4.380.264
Female43.291.220.33-3.110.835
Campylobacter, all patients77.220.970.39-2.000.868
20-6022.130.940.11-3.400.715
Male34.030.750.15-2.180.857
Female42.231.240.34-3.170.810
[Incidence of biliary tract cancer in patients ≥1 year after confirmed infection with Salmonella or Campylobacter, stratified by age and gender]
PB06-06 Management of Choledochal Cyst: An Institutional Review from a Tertiary Referral Center in Nepal
Sujan Shrestha, Nepal

S. Shrestha, B. Ghimire, P. Kansakar, R.S. Bhandari, P.J. Lakhey
GI and General Surgery, Tribhuvan University/Institute of Medicine, Nepal

Introduction: Choledochal cysts (CC) are a rare congenital cystic dilation of the biliary tract.
Method: This is a retrospective study of 32 consecutive patients of CC who underwent multidisciplinary management in last 2 and half years at a tertiary referral center from Nepal.
Result: A total of 32 patients, 9 males and 23 females were operated. The average age at diagnosis was 25 years (range from 2 to 56 years). The most common presenting symptoms were pain 31(96.88%), jaundice 10(31.25%) and mass 5 (15.63%). Triad of pain, jaundice and mass was present in 4 (12.5%). Transabdominal Ultrasonography (100%) was the initial diagnostic modality of choice followed by MRCP (68.75%), and CECT (31.25%). ERCP was done for stent placement in 3 (9.38%) patients with severe cholangitis. Type IVA (37.5%) was the most common type of CC followed by type IC (31.23%), type IB (15.65%), type IA (12.5%) and type IVB (3.12%). Abnormal pancreaticobiliary duct junction was observed in 3 (9.38%) patients. All patients underwent open cyst excision with Roux-en-Y hepaticojejunostomy (HJ). There were 2 patients who underwent relaparotomy for efferent loop obstruction and Peterson hernia. None of our patient had cholangiocarcinoma on pathological examination.
Conclusion: Choledochal cyst is rare cystic dilatation of biliary tract. Surgery (Cyst excision with Roux-en-Y hepaticojejunostomy) is treatment of choice. Although the incidence of cholangiocarcinoma is less, long-term surveillance is essential.
Keywords: Choledochal cyst (CC), Cyst excision with Roux-en-Y hepaticojejunostomy.
PB06-07 Synchronous Gastrointestinal Stromal Tumor and Ampullary Neuroendocrine Tumor in Association with Neurofibromatosis Type 1: A Report of Three Cases
Chol Kyoon Cho, Korea, Republic of

C.K. Cho, Y.H. Lee, E.K. Park, H.J. Kim, Y.S. Koh
Surgery, Chonnam National University Medical School, Korea, Republic of

Introduction: Neurofibromatosis type 1 (NF1) is an autosomal dominant hereditary disorder. The pathogenesis of NF1 is suggested to be an alteration of the NF-1 gene, which normally functions as a tumor suppressor. A mutation of NF-1 causes the development of viable tumors in various sites. On the other hand, the synchronous manifestation of a gastrointestinal stromal tumor (GIST) and neuroendocrine tumor (NET) in the background of NF1 is extremely rare.
Methods: Three patients showed synchronous ampullary NET and GIST in association with NF1 supported by postoperative histopathologic analysis. Surgical treatments, such as pancreatoduodenectomy and local excision were applied.
Results: No recurrence occurred during the postoperative follow-up period of 10, 9, and 2.7 years. Synchronous GIST and NET in the background of NF1 is extremely rare, but the possible coexistence of other tumors in NF1 patients is relatively higher than that in the general population. Furthermore, both NETs and GISTs occurring in NF1 patients tend to be smaller in size compared to that in the general population.
Conclusions: We reports three cases treated with surgical intervention along with the
long-term follow-up results. When NF1 patients present with vague abdominal discomfort, close attention must be paid to identifying the coexistence of other neoplasm.
PB06-08 Hemobilia due to Ruptured Pseudoaneurysm of Accessory Right Hepatic Artery: A Rare Cause of upper Gastrointestinal Hemorrhage
Yiing Yee Gan, Malaysia

Y.Y. Gan1,2, C.H. Lim1, K.C. Soon1, N.A. Nik Abdullah1
1Sarawak General Hospital, Malaysia, 2Universiti Sains Malaysia, Malaysia

Introduction: Anatomical variation of hepatic arteries are relatively common, but the occurence of pseudoaneurysm of hepatic arteries and its branches are rare,representing 0.01%-2% of all aneurysm.
Method: We observed a case of 53 year old lady with the presentation of obscure-overt gastrointestinal bleeding associated with obstructive jaundice.
Results: This patient had underwent computed tomography scan after repeated endoscopy failed to reveal the cause of bleeding, which has showed an arterially enhancing lesion at liver segment V with its supply from accessory right hepatic artery origin from superior mesenteric artery.This artery supplies segment V and segment VI of the liver. A subsequent digital substraction angiography demonstrated a large multilobulated pseudoaneurysm of this artery and successful embolization performed using gelfoam. A followup CT scan in 1 month later showed thrombosed pseudoaneurysm.
Conclusions: This case has taught us that high suspicion of biliary disorder should be made when gastrointestinal bleeding is associated with jaundice. An early imaging should be considered when repeated endoscopy is unable to determine the cause of bleeding.Non operative management using transcatheter embolisation can be the treatment of choice in pseudoaneurysms to avoid potentially risky and difficult surgery.
PB06-09 Multiple Cholecystoenteric Fistulas and Choledochal Cyst Identified during Laparoscopic Cholecystectomy: An Interesting Case
Tamara Floyd, United States

T. Floyd, K. Harnois, M. Jacobs
Surgery, Ascension Providence Hospital, United States

Introduction: Cholecystoenteric fistula is a rare complication of gallbladder disease and cholelithiasis, and are typically discovered incidentally during cholecystectomy. Identification and proper management with division and closure of the fistula is of paramount importance.
Type I choledochal cysts are the most common type of choledochal cysts and carry a risk of malignancy. Here, we report a rare case of a patient with cholelithiasis who during laparoscopy was found to have both cholecystoduodenal and cholecystocolonic fistulas, as well as a Type I choledochal cyst. We describe an algorithmic approach to definitive management.
Case description: A 55-year-old female presented with cholelithasis. During laparoscopy, a cholecystocolonic fistula, a cholecystoduodenal fistula, and a Type I choledochal cyst were found. Take-down of fistulae and cholecystectomy were performed followed by definitive biliary resection and reconstruction in a staged approach.
To our knowledge, this is the first case of a patient with two incidentally discovered cholecystoenteric fistulae and concurrent choledochal cyst. Furthermore, as avoiding definitive biliary bypass in the presence of a septic focus, we describe a step-wise approach to management.
Discussion: In patients with acute cholecystitis or choledocholithiasis, imaging frequently does not show evidence of gallbladder fistulas. Most commonly, these processes are only identified intra-operatively.
We present a rare case of a patient with multiple cholecystoenteric fistulae and a Type I choledochal cyst discovered intra-operatively. This case report highlights an algorithmic approach to the management of not only dual or multiple cholecystoenteric fistulas, but also a concurrent Type 1 choledochal cyst.
PB06-10 Mirizzi Syndrome: Diagnosis and Management of a Challenging Biliary Disease
Hafiz Ahmed Nazmul Hakim, Bangladesh

H.A. Nazmul Hakim1, H. Rabbi2, K. Islam3, T. Talukder3
1Surgery, Dhaka Medical College Hospital, Bangladesh, 2Hepatobiliary, Birdem Hospital, Bangladesh, 3Surgery, Dhaka Medical College, Bangladesh

Background: Mirizzi syndrome is difficult to diagnose pre-operatively and treat, represent a particular challenge for hepatobiliary surgeons. Furthermore, it increases the risk of intra-operative biliary injury. The aims of this study were to point out some particular aspect of diagnosis and treatment of this condition that will be helpful for the surgeons.
Methods: We retrospectively reviewed all records of the patients, surgically treated for Mirizzi syndrome from January 2013 to January 2018 in Dhaka Medical College Hospital, Shaheed Suhrawardy Medical College Hospital and BIRDEM General Hospital.
Results: During the study period, a total of 1320 cholecystectomy were performed, out of which 50 patients were diagnosed with Mirizzi syndrome, Roux-en-Y hepaticojejunostomy was the treatment of choice and subtotal cholecystectomy were done for 7 cases and laparoscopic cholecystectomy for 2 cases. There was no post-operative mortality. Two cases of biliary fistula resolved with conservative management and another case required percutaneous treatment for resolution of an intraperitoneal postoperative collection.
Conclusion: Mirizzi syndrome continues to be a disease of difficult diagnosis and treatment. General surgeons without long experience in hepatobiliary surgery should refer the patient to a specialized hepatobiliary surgical center.
PB06-11 Differential Diagnosis of Acute Cholecystitis with an Atypical Ultrasound Image
Yulia Stepanova, Russian Federation

M. Kirillova1, Y. Stepanova2
1V.P. Demikhov City Clinical Hospital (CCH No. 68), Russian Federation, 2Oncology, A.V. Vishnevsky National Medical Research Center of Surgery, Russian Federation

Objective: To improve the ultrasound diagnosis of the gallbladder (GB) pathology by developing a diagnostic algorithm for the atypical ultrasound image of acute cholecystitis.
Materials and methods: 5600 patients with acute pathology of GB were examined in CCH No. 68 in 2010-2018. Of these, 360 patients at primary ultrasound revealed changes in the GB that didn't allow them to be attributed to the image of acute cholecystitis. Patients were divided into 2 groups: the 1st group included 120 (33.3%) patients whose changes in the GB included thickening of the wall without increasing the size of the GB, the 2nd - 240 (66,7%) patients with an increase in the size of the GB, but without changes in the wall.
Results: In a retrospective analysis in the first group, the following changes were diagnosed: Mirizi syndrome - in 10 patients, GB tumor - 20, reactive changes in the wall against other diseases and conditions - 62, biliary digestive fistula - 12, perforation of the GB at acute cholecystitis - in 16 patients.
In the second group, only 30 patients were diagnosed with acute cholecystitis, including empyema of GB - in 8 patients, enlargement of GB wall' was regarded as a manifestation of congestive or "hungry" GB, which does not require specific treatment in 210 patients.
Conclusions: After comparing the findings of ultrasound examinations of GB and final diagnoses, an analysis of inconsistencies was performed. The diagnostic criteria to help make a differential diagnosis between various pathologies of GB were formulated.
PB06-13 Clinical and Surgical Relevance of Current Classification Systems of Complex Bile Duct Injuries after Cholecystectomy
M. Di Salvo, Italy

M. Di Salvo, D. Letizia, R. Isernia, G. L'Episcopia, S. Roselli, M.F. Valentini, L.G. Lupo
Dep. Emergenza e Trapianti - Chirurgia Epatobiliare e Trapianto di Fegato, Università di Bari, Italy

Introduction: The Classification of bile duct injuries (BDI) after cholecystectomy is a clinical challenge for surgeons because of their heterogeneity in site and clinical presentation and is relevant for decision making and treatment and to allow comparison.Although the outcome of BDI is related to the type, aetiology, time interval between lesion and diagnosis, and between diagnosis and treatment and to the presence of sepsis, however the current systems are mainly based on anatomical features not considering the wide spectrum of clinical presentation.
Aim: This study aims to evaluate the performance of 5 classification systems, namely Strasberg, Stewart-Way, Siewert, Hannover and ATOM, to discriminate complex BDI (cBDI, Strasberg's E ) patterns and the relative surgical treatment.
Methods: This study includes 24 selected patients with cBDI out of a total 56 admitted with BDI, studied by MRI and ERCP and surgically treated between 2010 and 2019. Data were retrospectively collected and patients were classified according to the 5 systems. X2-test was adopted.
Results: The Strasberg, Stewart-Way and Siewert systems allowed to classify 19/24 patients,the Hannover's 22/24 and ATOM all patients, p< 0.049. All patients underwent biliary reconstruction with poliduct-jejunostomy, 3 required vascular repair and 3 major liver resection; one patient died from septic shock.
Conclusions: The ATOM classification performed better than other in this small selected cohort of patients with cBDI. Future classifications might include clinical variables to better guide the therapeutic decision.
PB06-14 Relationship with Significantly Raised CA-19.9 with Biliary Duct Stones: Early Experience in Dept. of Hepatobiliary Surgery, ShSMCH, Bangladesh
Akhter Ahmed, Bangladesh

A. Ahmed
Surgery, Shaheed Suhrawardy Medical College, Dhaka, Bangladesh

Introduction: Conventionally it is assumed that raised level of CA 19-9 (Carbohydrate antigen 19.9) is related to malignancies of liver, pancreas and biliary tract. During dealing with a patient with bile duct stones, we surprisingly noticed significant rise of CA 19-9 level. Then we decided for a study to explore the relationship of significantly raised CA 19-9 with biliary tree stones.
Method: We randomly encountered a total of 138 diagnosed biliary stone cases at department of Hepatobiliary Surgery, Hepatology and Gastroenterology over one year time. All patients were evaluated by routine blood test, USG, MRCP and CA 19-9 levels. CA 19-9 levels were also measured at 5th post-operative day and at 4 week follow up day. During ERCP, cytology was taken, and bile duct wall was sent for histopathology in operative cases.
Result: Mild and moderate raise in CA 19-9 level (38-1000U/ml) were noted in 15 cases and significantly raised (> 1000 U/ml) in 8 cases. 3 of these cases showed simultaneous presence of hepatic micro-abscess and 6 cases showed angulation, dilatation or tortuosity of CBD in MRCP. All histopathology reports were proved benign. In 4 weeks post ERCP/ operation follow up, CA 19-9 levels became normal in all cases except 3. However, they also showed significant reduction in CA 19-9 level.
Conclusion: Significantly raised level of CA 19-9 is associated not only with Hepatobiliary malignancies but also with complicated bile duct stone diseases.
PB06-17 Radical Cholecystectomy for GB Tuberculosis Mimicking GB Neck Carcinoma with Obstructive Jaundice
Subhash Soni, India

S. Soni1, V. Varshney1, P. Elhence2
1Dept. of Surgical Gastroenterology, All India Institute of Medical Sciences, India, 2Dept of Pathology, All India Institute of Medical Sciences, India

Introduction: Isolated Hepatic-pancreato-biliary tuberculosis is a very rare condition and gall bladder tuberculosis is still rarer. Majority of patients with GB tuberculosis diagnosed in symptomatic gall stone disease, post cholecystectomy and only a few cases reported with GB neck involvement causing obstructing jaundice. We report a rate case of gall bladder tuberculosis presented as suspected GB neck carcinoma with obstructive jaundice.
Methods: 55 year male presented with complaints of painful progressive jaundice since 2 month. H/o loss of appetite and significant loss of weight over last 2month. CECT abdomen and MRCP was s/o circumferential soft tissue thickening with high grade stenosis at gall bladder neck, CHD and superiorly extending upto confluence. EUS showed mass in GB neck extending to CHD around 2.5cm and EUS guided FNAC inconclusive. His total serum bilirubin was 6.9 and CA 19.9 was 271.9.
Results: In view of ? carcinoma GB neck with obstructive jaundice he we underwent radical cholecystectomy with CBD excision. Intra operatively there is 3x3 cm mass present at GB neck and CHD reaching upto confluence. Post-operative period was grossly uneventful and patient was discharged on POD 7. Final histopathology was s/o Necrotizing granulomatous inflammation, consistent with tubercular cholecystitis. Proximal CHD also showing Necrotizing granulomatous inflammation. ZN stain shows an occasional bacilli. Following biopsy he was started on ATT and now at 6 months follow up he is totally asymptomatic.
Conclusion: Gall bladder tuberculosis can present as carcinoma GB with obstructive jaundice and very difficult to diagnose preoperatively.
PB06-18 Recurrent Acute Pancreatitis in Remnant Choledochal Cyst after Excision
Prekshit Chhaparwal, India

P. Chhaparwal, P. Varshney, A. Nagar, A. Sharma
Surgical Gastroenterology, Mahatma Gandhi Medical College and Hospital, India


Choledochal cyst (CDC) treatment requires CDC excision and Roux-en-Y hepaticojejunostomy. These patients with CDC are known to have anomalous pancreatic bile duct junction (APBDJ) leading to complications indicating surgery as a definitive treatment. Some of these patients who have larger remnant of distal bile duct after CDC surgery have recurrence of pancreatitis and malignancy. Material and methods: We report three cases of CDC who were operated earlier with CDC excision (1 year to 12 years in past) and presented with recurrent pancreatitis. On evaluation, all three cases had a remnant of distal common bile duct persisting even after the prior CDC surgery. MRCP revealed a dilated intrapancreatic CDC remnant with hypointense foci (stones or protein plugs). An ERCP was suggestive of a sludge filled dilated CDC remnant with APBDJ.
These patients had undergone a completion distal CBD excision. After the procedure, they have no recurrence of pancreatitis.
Conclusion: CDC remnants have persistent reflux of pancreatic juice in remnant CBD due to APBDJ. This result in protein plug/calculi formation in the remnant CBD. This along with a lesser chance of distal CBD getting spontaneously cleared (due to absence of bile flow post CBD excision), predisposes to swelling in the distal CBD, result in recurrent acute pancreatitis.
Keywords: Choledochal cyst (CDC), anomalous pancreatic bile duct junction (APBDJ), Recurrent acute pancreatitis
PB06-19 Obstructive Jaundice Secondary to Hepatobiliary Tuberculosis: A Tertiary Government Hospital Experience in the Philippines
Alain Neil Ancheta, Philippines

A.N. Ancheta, D. Ang, A. Yap, R. Domingo, A. Erasmo
Hepatobiliary Surgery, Jose R. Reyes Memorial Medical Center, Philippines

Introduction: The incidence of extrapulmonary-tuberculosis in the Philippines is 1.9%. Patients of lower socio-economic status are particularly vulnerable due to community factors, poor health seeking behaviours and less access to specialized health centers. In addition the cost of diagnosing and treating hepatobiliary-tuberculosis is prohibitive. Complicating the management is the lack of protocol in diagnosing and treating this rare disease. This study aims to review cases of obstructive jaundice secondary to hepatobiliary-tuberculosis treated in Jose R. Reyes Memorial Medical Center.
Methods: Charts of patients treated for obstructive jaundice secondary to hepatobiliary-tuberculosis from January to December 2019 were reviewed and analyzed.
Results: There were 142 cases treated for obstructive jaundice from all etiologies. Among these, 10 cases were caused by hepatobiliary-tuberculosis(Table 1). Age ranged from 19 to 56 years old with 1:1 male/female ratio. Most common reason for consultation is abdominal pain progressing to jaundice which may last from several months to a year. Three patients had a history of previous pulmonary-tuberculosis treatment.
Eight patients had histology consistent with tuberculosis(Figure 1). The other two were diagnosed based positive bile TB PCR and imaging respectively. Six patients had extrahepatic ductal obstruction while 4 had hilar/intrahepatic ductal involvement. Seven out of 10 patients were managed with biliary-enteric bypass. There was 1 morbidity, managed conservatively, and no mortality.
Conclusion: Treatment of hepatobiliary-tuberculosis depends on the available expertise and equipment. Biliary-enteric bypass is an option for centers lacking ERCP or PTBD; however long-term follow up is needed.
Age19-53 years old
Sex Ratio1:1
SymptomsAbdominal Pain and Jaundice (n6); Jaundice (n3); Fistula (n1)
Symptom Duration1 week to 4 years
History of TuberculosisNone (n7); Yes (n3)
DiagnosisHistopathology (n8); TB PCR (n1); Imaging (n1)
Chest X-ray FindingsUnremarkable (n7); Tuberculosis (n2); Pleural Thickening (n1)
Stricture LocationExtrahepatic (n6); Intrahepatic (n4)
Operation DoneBiliary Enteric Bypass (n7); PTBD (n1); ERCP (n1); Tube Choledochostomy (n1)
Mortality/MorbidityNone (n9); Anastomotic Leak (n1)
[Table 1: Patient Summary N(10)]

[Figure 1: Extensive TB Granuloma of the Liver]
PB06-25 Three Cases of Unusual Solitary Intrahepatic Biliary Cyst in Adults
Shi-Zhong Yang, China

S.-Z. Yang, L. Gong, X.-B. Feng, B. Shu, Q. Lu, J.-H. Dong
Tsinghua University, Department of Hepatopancreatobiliary Surgery, Beijing Tsinghua Changgung Hospital, China

Introduction: Because of its rarity, solitary intrahepatic biliary cyst (SIBC) is often misdiagnosed and under-recognised. The aim of the present study was to focus the attention on this disease and improve its diagnosis and treatment.
Methods: 3 cases of SIBC were reported, and the clinical features and lessons were presented.
Results: Case 1 was found a solitary cyst involving segments 4,5,8. She was misdiagnosed as simple liver cyst. Before admission, she received laparoscopic liver cyst fenestration followed by two open surgeries including cystojejunostomy and jejunostomy because of biliary fistula. She was cured through mesohepatectomy in our hospital. Case 2 had a cyst involving the confluence of left and right hepatic ducts. He underwent local cyst excision and biliodigestive anastomosis in the local hospital. Recurrent cholangitis occurred after the surgery. Left hepatectomy with Roux-en-Y hepaticojejunostomy was performed for the treatment of biliary stricture in our hospital. Case 3 was found a solitary cyst at hepatic hilum by ultrasonography. MRI and contrast-enhanced CT scans indicated multiple stones in the cyst and local cyst wall thickening. He underwent left hepatectomy with Roux-en-Y hepaticojejunostomy and regional lymphadenectomy. Histologically, SIBC was confirmed in all 3 cases and papillary adenocarcinoma was found in the case 3.
Conclusion: To our knowledge, the present series of 3 cases represent the largest series of SIBC reported to date. SIBC should be considered in the differential diagnosis in patients with a solitary cystic mass at the hepatic hilum. Aggressive hepatectomy may be recommended as a curative treatment.
CaseSexAgeSymptomsPrevious imagesLocation of biliary cystDiameter of biliary cyst (cm)Previous surgery (times)Follow-up period (month)prognosis
1F30yAbdominal painUS/CT/MRCPHepatic hilum8.5325Symptom free
2M70yAbdominal painUS/MRCPHepatic hilum2.8133Symptom free
3F33yFever/ jaundiceUS/CECT/MRCPHepatic hilum5.0none19Symptom free/ no recurrence
Abbreviations: F=female M=male y=year US=ultrasonography; CT=computed tomography; MRCP= magnetic resonance cholangiopancreatography; CECT=contrast-enhanced CT;
[Table 1: Clinical data of 3 patients with solitary intrahepatic biliary cyst]

[Figure 1: Radiological findings of 3 cases of solitary intrahepatic biliary cyst]
PB06-26 Study of a Rapid Detection of Causative Bacteria in Cases of Acute Cholangitis and Cholecystitis Using a Multichannel Gene Autoanalyzer
Ryutaro Watanabe, Japan

R. Watanabe1, M. Kuroda2, K. Asai1, M. Kujiraoka1, H. Moriyama1, M. Watanabe1, Y. Saida1
1Department of Surgery, Toho University Ohashi Medical Center, Japan, 2Laboratory of Bacterial Genomics, Pathogen Genomics Center, National Institute of Infectious Diseases, Japan

Background: Acute cholangitis and cholecystitis are severe conditions, which are becoming increasingly resistant to antimicrobial treatment owing to inappropriate administration of therapeutics. “Bacterial nucleic acid and antimicrobial resistant gene detection simultaneously” is adopted as a medical fee item for sepsis. In our study, we evaluated the rapid detection of causative bacteria in cases of acute cholangitis and cholecystitis using a multichannel gene autoanalyzer (Verigene® system).
Methods: This study included 108 patients who were diagnosed with acute cholangitis or cholecystitis from June 2015 to November 2018. Bile samples were collected and evaluated by bacterial culture test and Verigene® assay.
Results: The most commonly isolated bacteria were Escherichia coli (E.coli) (23.3%), including six extended spectrum beta-lactamase (ESBL) -producing E. coli. Of the patients with positive bile cultures, bacteria were detected in 35.7% cases via the Verigene® system. Four (66.7%) of the ESBL-producing E. coli were identified as having the CTX-M gene. Detection rates of the Verigene® system significantly increased when the number of bacterial colonies were more than 106 CFU/mL. These cases with colony of more than 106 CFU/mL exhibited significantly higher inflammation, suggesting the presence of infection.
Conclusions: It was suggested that the multichannel gene autoanalyzer is a new system for the rapid detection of causative bacteria in patients with infectious acute cholangitis and cholecystitis.
PB06-27 Lemmel's Syndrome Leading to Enterolith Ileus
Ranah Lim, Australia

R. Lim1, I. El-Haque1, N. Merrett1,2
1General Surgery, Bankstown-Lidcombe Hospital, Australia, 2University of Western Sydney, Australia

Introduction: Lemmel's syndrome is obstructive jaundice caused by periampullary duodenal diverticulum in the absence of choledocholithiasis or tumour. We describe a unique presentation of Lemmel's sydrome and enterolith ileus.
Method: 67 yo female presented to our emergency department with fever, epigastric pain and vomiting. Patient had a past history of cholecystectomy. Investigations demonstrated raised inflammatory markers and cholestatic LFTs. Biliary tract ultrasound showed a 1.6 cm CBD with dilated intrahepatic ducts and a 5cm complex peripancreatic cystic mass. CT confirmed this mass as a duodenal diverticulum. During ERCP, 5cm periampullary duodenal divertculum containing a large enterolith causing extrinsic compression on the CBD. Attempts to remove the enterolith during ERCP failed. Sphincterotomy and stent insertion was performed. Patients biliary symptoms resolved and she was discharged for further outpatient investigation and assessment. Five days later, she represented with severe lower abdominal pain and vomiting. CT scan demonstrated distal small bowel obstruction with a 4.2 x 2.8 cm intraluminal filling defect at the transition point. At laparotomy, a large solid intraluminal mass was found at the point of obstruction which was removed using enterostomy.
Result: During treatment for Lemmel's syndrome, endoscopic disimpaction of the enterolith and its removal or disintegration is essential to prevent its passage enbloc into small bowel. Enterolith Ileus should be considered in patients representing with SBO post Lemmel's treatment.
Conclusion: Enterolith dislodgment, if not retrieved, can lead to ileus and should be considered as the likely cause of SBO post treatment of Lemmel's syndrome.
PB06-28 Study on Bacteremia Following Extended Hepatectomy for Biliary Cancer
Junki Fukuda, Japan

J. Fukuda, K. Tanaka, Y. Nakanishi, T. Noji, K. Okamura, T. Asano, T. Nakamura, T. Tsuchikawa, S. Hirano
Hokkaido University Graduate School of Medicine, Japan

Introduction: Infectious complications in hepatectomy for biliary cancer have still frequently occurred. Postoperative bacteremia requires systemic intensive care and it's important to provide an initial treatment by appropriate antibiotics. Results of cultures in patients who suffered bacteremia were investigated in this study.
Method: We reviewed 179 patients who underwent hepatectomy for biliary cancer from January 2008 to December 2018. Risk factors of bacteremia, and the relationship between bacteria caused bacteremia and those cultured from bile and abdominal drainage fluid.
Results: There were 120 males, and the median age was 69 years old. There were 179/ 33/ 14 cases of bile duct cancer/ intrahepatic cholangiocarcinoma/ gallbladder cancer. Right hepatectomy/ left hepatectomy/ right trisectionectomy/ left trisectionectomy/ central bisectionectomy were performed in 81/ 76/ 7/ 14/ 1 patients. Bacteremia was occurred in 41 patients (23.0%). Risk factors of bacteremia were long operative time (p=0.01) and intra-operative blood transfusion (p=0.01). Bacteremias were associated with abdominal abscess (20.2%), cholangitis (14.3%), bile leakage (13.4%). Total incidences of bacteremia were 88 times and 24 kinds of bacteria were detected in blood culture. Postoperative bile/ abdominal drainage cultures were collected in 34/34. The consistency of blood culture with bile/ abdominal drainage cultures were 58.8%/ 52.9%. It was 63.2％ when at least one of the drainage cultures was consistent with blood one.
Conclusion: Bacteria cultured from postoperative bile and abdominal drainage fluid matches with those from bacteremia in more than half of the patients. The results of these cultures could be considered in selection of antibacterial drug in immediate-use.
PB06-29 Five Year Experience of Bile Duct Injury in Yangon Specialty Hospital, Myanmar
Pyae Kyaw, Myanmar

P. Kyaw1, M. Htin1, L.T. Thein1, S.M. Thein1, S.A.N. Oo2, T.T. Mar1
1Hepatobiliary and Pancreatic Surgery, University of Medicine 1, Myanmar, 2Hepatobiliary and Pancreatic Surgery, University of Medicine 2, Myanmar

Introduction: HBPS department of YSH is one of the two dedicated HBP units in the Country of 55 million. BDI is usually tackled by HBP surgeons. OUr annual incidence of 0.8% seemed a bit higher than most of the published data but it included referred BDI cases.
Method: Hospital based, retrospective case series based on hospital data.
Results: There were 43 cases of BDI in 5 years of which, 72% (31 cases) is due to benigh cases and 33% (12%) cases to malignant cases. Post laparoscopic cholecystectomy accounted for majority (60%) of the BDI due to benign disease while post hepatectomy cases for cholangiocarcinoma accounted for 40% of BDI due to malignant disease. Most of the BDI presented with bile leak but 10% with stricture.
DIscussion: Various methods (surgery, interventional radiology and endoscopy) performed for BDI in the study period will be discussed with outcome with regard to mortality and morbidity.
Conclusion: Early recognition and multidisciplinary approach is the key for management of BDI.
PB06-32 Complicated Duodenal Ulcer Postcolecystectomy in a Third Level Hospital in Mexico
Pablo Villegas, Mexico

P. Villegas, S. Pimentel, Y. Nacud
Digestive and Endocrine Surgery, IMSS UMAE 25, Mexico

Introduction: The migration of laparoscopic staple with complications such as duodenal ulcer is a rare postcolecystectomy complication. Complication that can occur at any time, but usually 2 years post cholecystectomy. In this report, a case of complicated duodenal ulcer that occurred 1 year after laparoscopic cholecystectomy is reviewed.
Case Presentation: 42-year-old male, with bleeding from non-variceal upper gastrointestinal tract and severe epigastric pain. Surgical history of laparoscopic cholecystectomy
CT scan: Plastron complex in vascular bed topography.
The patient is scheduled for emergency surgery, laparotomy is performed with the following Findings: lax adhesions of the colon and liver, and omentum to the liver, firm adhesion of the first duodenal portion to the liver bed, with a 3 * 3 cm hematoma in said area that when opening its capsule, mucous duodenal evidence in said region with laparoscopic clips included in the tissue.
Procedure performed Billroth II
Histopathological report: duodenal ulcer, negative for neoplasia, viable surgical resection edges.
follow-up without complications.
Discussion: Cholelithiasis is common and laparoscopic cholecystectomy is the treatment of choice.
Being one of the most performed surgeries since its introduction, surgical hemostatic clips have been widely used and are generally considered safe. Despite the increasing number of annual cholecystectomies performed, postcolecystectomy clip migration (PCCM) remains rare. Apart from migration to the biliary tree, is the cause of other complications such as duodenal ulcer or clip embolism.
Conclusion: Complications such as duodenal ulcer of clips should always be present in patients with abdominal pathology and a history of recent cholecystectomy.
PB06-33 NET of Extrahepatic Biliary Tract: A Case Report with Review of the Literature
Raffaele Romito, Italy

L. Portigliotti, F.M. Nicolosi, O. Soresini, F. Frosio, F. Colli, F. Maroso, R. Romito
Surgery, AOU Maggiore Hospital, Italy

Neuroendocrine tumors (NETs) of the extrahepatic bile ducts are extremely rare and represents only 0.1%-0.4% of the cases.
We present the clinical course and radiological findings of a patient with an extrahepatic bile duct NET and a literature review about the management of this rare neoplasm.
We present a case of an 58-year-old man with NET of the common bile duct that was discovered on abdominal ultrasound during a medical examination. He was admitted to our hospital with a diagnosis of hepatic hilar tumor.EUS+FFNAB confirm the diagnosis Computed tomography and Magnetic resonance cholangiopancreatography revealed a neoplasm of 28 x 24 mm of the common bile duct without any nodes and distant metastases . The patient underwent to surgery with excision of the biliary ducts and tumor followed by Roux-en-Y anastomosis. Histological results showed NET grade 2.Free margin
We review the literature about the correct management and treatment of these neoplasms. Preoperative diagnosis of NETs is difficult because of their rarity. A definitive diagnosis is usually established intraoperatively or after histopathological evaluation. For these tumors, surgical resection is currently the only treatment modality for achieving a potentially curative effect.
PB06-34 Fetus in Fetu with Jaundice - A Rare Presentation of a Rare Disease
Sifat Khan, United Kingdom

S. Khan1,2, M.A.U. Huq1
1Dhaka Medical College Hospital, Bangladesh, 2Birmingham Children's Hospital, United Kingdom

Fetus in fetu is a rare mysterious medical phenomenon in which an acardiac fetiform mass is commonly located in abdomen of a neonate or infant. We report on a case of a 7 month-old girl with a gradually enlarging right upper abdominal mass and progressive jaundice, whose plain abdominal radiograph, ultrasonography, and CT scan revealed a mass in which the contents favor a fetus in fetu. Obstructive jaundice was caused by billiary obstruction by FIF.
Per-operative findings of deformed fetus presenting well formed lower limbs, one rudimentary upper limb, spina bifida and anencephaly was noted. It was surrounded by a separate gestational sac about 22 wks size. Umbilical cord was communicated with the mesenteric vessels. Cyst contained yellowish fluid. Liver was shrunken & cirrhotic. Umbilical cord transfixed and separated. Deformed fetus was removed and gestational sac excised. Fetus weighed 415 gm. Liver biopsy was taken. Her immediate and early post-operative period was uneventful. Patient was discharged on 11th POD, with follow up advices. Unfortunately, patient did not come for follow up.
Keywords: Fetus in fetu, Obstructive jaundice in infant, Liver cirrhosis in infant.
PB06-35 Laparoscopic Hepatico-jejunostomy for Benign Bile Duct Strictures - Our Experience
Manash Ranjan Sahoo, India

M.R. Sahoo, S. Bajoria
Department of Surgery, All India Institute of Medical Sciences, India

Introduction: The incidence of bile duct injuries (BDI) after cholecystectomy is around 0.6%. Biliary strictures following BDI is a worrisome complication. Laparoscopic hepatico-jejunostomy for benign biliary strictures has been a rarely attempted operation. The aim of this study is to describe our experience in the laparoscopic approach for biliary stricture repair- currently not attempted by many centres.
Methods: A retrospective study of eleven (11) patients with benign biliary strictures secondary to cholecystectomy, operated between 2012 and 2020, was conducted. Demographics, co-morbidities, presenting symptoms, details of index surgery, type of lesion, pre-operative and post-operative workup and therapeutic interventions were recorded. The biliary strictures were staged according to the Bismuth-Strasberg classification. A side to side anastomoses with Roux-en-Y reconstruction was performed in all cases. Complications, mortality, and long-term follow-up were recorded.
Results: Eleven patients with benign biliary strictures were operated. the female to male ratio was 3:2. The mean age of the population under study was 30 years. All eleven cases operated were E3 according to the Strasberg classification. The operative time recorded was ranged between 240 - 480 mins. The median value of bleeding was 200 mL (range 50-1100 mL). Oral intake was started in the first 48 hrs. No bile leak was noted in any of our patients. No patients have underwent re-intervention till date. No mortality was recorded. The maximum follow-up was 48 months (Range 2-48 months).
Conclusion: The benefits of minimal access techniques may be utilized successfully in the management of benign biliary strictures with acceptable morbidity.
PB06-36 IgG4 Cholangiopathy Mimicking Cholangiocarcinoma: A Case Series
Nor Alia Mohd Noor, Singapore

N.A. Mohd Noor, Y.P. Tan, C.W.T. Huey
Hepatopancreatobiliary Surgery, Tan Tock Seng Hospital, Singapore

Introduction: IgG4 cholangiopathy is a rare autoimmune condition that is poorly understood. It can mimic several other diseases such as primary or secondary biliary or sclerosing cholangitis, and even cholangiocarcinoma.
Methods: We report our case series of 3 patients who first presented with painless obstructive jaundice, and were subsequently discovered to have IgG4 cholangiopathy. We discuss the interesting clinical features and outcomes of each patient.
Results: All 3 patients were male, with a mean age of 64 years (range 54-71 years). Initial imaging for all 3 patients showed lesions at the hepatic hilum, suspected to be malignant strictures. Ca19-9 levels were elevated. Our first patient underwent an open extended right hepatectomy. Histology revealed sclerosing cholangitis with increased IgG4 plasma cells. Our second patient had elevated IgG4 serum levels, and was diagnosed to have IgG4 cholangiopathy. He responded well to a trial of steroid therapy, and interval imaging 3 months later demonstrated resolution of the hilar mass. The third patient was offered resection for a suspected cholangiocarcinoma, but opted for traditional medicine. 3 years later, he represented to our clinic, and repeat imaging showed stable disease with no progression of the lesion. None were associated with autoimmune pancreatitis.
Conclusion: IgG4 cholangiopathy is an important differential diagnosis to be considered in cases of suspected malignant hilar strictures in middle aged-men. Serum IgG4 levels should be included as part of the pre-operative work up, in order to avoid unnecessary interventions and their associated morbidities.
PB06-37 Unusual Cause of Epigastric Pain: Torsion of Falciform Ligament
Jae-Woon Choi, Korea, Republic of

J.-W. Choi
Chungbuk National University, Cheong-ju, Korea, Republic of

A 37-year-old male came with complaints of epigastric pain for 3 days. The pain was continuous in nature and was not radiating to the back. He had no nausea, vomiting, or fever. On examination, there was epigastric tenderness in the epigastric and right hypochondrium region. CT showed localized fat infiltration along the falciform ligament and adjacent hepatic parenchymal hyperemia. Torsion of the falciform ligament is an extremely rare disease that leads to severe acute abdominal pain. This condition is well managed conservatively with anti-inflammatory analgesia. However, we have performed surgical intervention (division of falciform ligament) because he had a severe pain despite supportive care.
PB06-39 Is Pancreatic Cancer More Prevalent in Poor Neighborhoods? Zip Codes are the New Influencers in Determining Cancer Survival
Cataldo Doria, United States

C. Doria, E. Schwartz, P. De Deyne, K. Yatcilla, J. Chung, S. Ranieri Dolan
Capital Health, Cancer Center, United States

Introduction: The purpose of this study was to determine if the prevalence of pancreatic cancer changes based on patients zip codes. Our hypothesis was that low socio economic status (SES) is associated with increased prevalence of pancreatic cancer.
Methods: We interrogated a convenience sample from our cancer center registry and obtained 479 subjects diagnosed with pancreatic cancer between 2010-2018. We selected subjects (328) by zip code, representing the plurality of the cases in our catchment area. Outcome variables were overall survival and socio-economic status; predictor variables were recurrence, insurance, type of treatment, gender, cancer stage, age, and gender. We converted zip code to municipality and culled data using Adjusted Gross Income (AGI, FY 2017) We then created groups using a cutoff at filings of >$100,000 of AGI; Low SES = municipalities where ≤5% of the filings were over $100,000, Mid SES = municipalities where between 5%-40% of the filings were over $100,000, High SES = municipalities where ≥40% of returns were over $100,000. Comparative statistical analysis was performed using Chi-square for nominal and ordinal variables, a two-way ANOVA test was used for continuous variables, p- value was set at 0.05.
Results: Although it was not statistically significant different, it appears that pancreatic cancer was diagnosed more often in poor neighborhoods.
Conclusion: Access to care, exposure to known risk factors, optimal nutritional status, overall fitness, co-morbidities all play a role in pancreatic cancer. Our study shows that zip codes should be considered a new risk factor for developing pancreatic cancer.
PB06-40 Traumatic Neuroma of Bile Duct: A Case Report


M.F. Ahmad Nazlan1, I. Chik2, F. Fahmy2, A. Azman2, Z. Zuhdi2
1Surgery, Universiti Teknologi Mara, Malaysia, 2Surgery, National University of Malaysia, Malaysia

Introduction: One of the etiologies of obstructive jaundice, is biliary stricture. Biliary stricture can present as either due to a benign or malignant cause. Traumatic neuroma rarely presents as a cause of obstructive jaundice, and is seen in literature usually following cholecystectomy or liver transplant.
Methods: We present a case of a 30-year old woman, who presented with acute cholangitis 7 years after an elective laparoscopic cholecystectomy.
Results: As this patient presented with cholangitis post surgery, she was stented and eventually underwent biliary reconstruction. The histopathology of the resected duct revealed a traumatic neuroma. In this case report, we review literature of traumatic neuroma presentation and its management.
Conclusion: Traumatic neuroma of the bile duct can present with symptoms of biliary stricture. Although it is rare, it should be considered as a cause of benign biliary stricture.
PB06-42 Biliary Pressure Monitoring and its Clinical Correlation in Patients with Obstructive Jaundice
Sakthivel Harikrishnan, India

S. Harikrishnan1, J. Sathyanesan1, T. M2
1Department of Surgical Gastroenterology and Liver Transplant, Government Stanley Medical College, India, 2Department of Surgical Gastroenterology and Liver Transplant, government Stanley Medical College, India

Introduction: Biliary pressure has been postulated to have a direct impact on cholangiovenous reflex and cholangitis in patients with obstructive jaundice .Only limited human studies are available regarding biliary pressure monitoring.
Methods: A total of 30 patients with obstructive jaundice either benign or malignant and who didn't undergo any interventional or surgical procedure for relief of the jaundice were included in the study.The clinical and demographic details were noted and Liver function test was taken on the day of biliary decompression. Bile pressure was monitored intraoperatively with a pressure transducer system proximal to the obstruction. In patients who undergo PTBD ,bile pressure was noted immediately after inserting the Chiba needle.
Results: A total of 30 patients were included in the study (19 males and 11 females). The mean age of the patients included were 55.9 years.The etiology of obstructive jaundice was periampullary carcinoma in 13 patients , carcinoma head of pancreas in 3 patients, carcinoma gallbladder in 3 patients , hilar cholangiocarcinoma in 6 patients ,postcholecystectomy biliary stricture in 1 patient ,Chronic pancreatitis with distal CBD compression in 2 patients, Post Liver transplant CBD stricture in 1 patient and choledocholithiasis with cholangitis in patient. (19 distal obstruction and 11 proximal obstruction).The mean biliary pressure in patients with distal obstruction was 22.3 and in patients with Proximal obstruction was 18.09. The highest recorded biliary pressure was 52 in periampullary carcinoma.
Conclusions: First study of its kind to document the biliary pressure and the bile characteristics in obstructive jaundice of various etiologies.
PB06-43 Conservative Management of Bile Leak Secondary to an Accessory Duct of Luschka
María Sánchez, Paraguay

M. Sánchez1, F. Heiberger2, R. Rojas2, R. Sánchez2, A. Bordón2
1Cirugia, Hospital de Clínicas, Paraguay, 2Cirugia Sala X, Hospital de Clínicas, Paraguay

Introduction: Post cholecystectomy bile leaks are rare, have an incidence of 0.1-1%, and regardless of their nature, most cannot be detected during surgery. In 5-30% they correspond to a Luschka duct, which are small ducts that originate in the right hepatic lobe, extend to the gallbladder bed and may or may not drain to the extrahepatic bile ducts. The objective of this publication is to present the experience obtained in the minimally invasive and conservative management of a post-laparoscopic cholecystectomy bilioma due to leakage of the luschka duct.
Case: Female patient of 59 years, with Diagnosis : Multiple Myeloma + Cholelithiasis, undergoing laparoscopic cholecystectomy. Two days after surgery, a subphrenic collection is identified, which is drained percutaneously, with ultrasound guidance, and bilious fluid is obtained, approximately 800 cc. Subsequently, in the collagioresonance a bile duct lesion is identified, which is born from the right posterior bile duct and is directed towards the hepatic bed, with indemnity of the main bile duct. The debit decreases progressively during the first week, presenting a negative debit 15 days after placement and the catheter is removed one week later. The evolution 1 month later is favorable, with normal ultrasound controls.
Conclusion: The minimally invasive treatment of bile leakage can be considered a safe option in patients with minor injuries, in order to avoid exposure to invasive procedures such as endoscopic retrograde cholangiography and its possible complications.
PB06-44 Bacterobilia in Biliary Surgery: Risk Factors
Francisco Juan Mattera, Argentina

M. Chahdi Beltrame1, M.L. Del Bueno1, J.G. Cervantes1, J.P.S. Duran Azurduy1, M. Poupard1, M.E. Lenz Virreira1, E.G. Quiñonez1, F.J. Mattera2
1Hepatobiliar Surgery and Liver Transplantation, Hospital el Cruce, Argentina, 2Hepatobiliary Surgery and Liver Transplantation, Hospital el Cruce, Argentina

Introduction: Procedures over the biliary tree are controversial prior biliary surgery and may contribute to bacterobilia which can also lead to higher rate of wound infections. We aim to analyze our population of patients under biliary surgery and the risk factors leading to bacterobilia.
Methods: Retrospective study from 2014 to 2019. Surgeries involving biliary tree were included. Prior biliary procedures and personal risk factors were analyzed. Univariate analysis using Student t test, Fisher and chi2; relative risk was measured and multivariate logistic regression was performed. Statistical significance level set at 0,05.
Results: Out of 86 biliary surgeries bacterobilia was documented in 45; 40 had some kind of biliary procedure prior final surgery (p=0,001), with a relative risk of 5,66 (CI 95% 1,8-17,3). When type of procedure was analyzed, percutaneous drainage showed no difference but ERCP had higher rate of bacterobilia (RR 3,14, CI95% 1,29-7,58). When previous cholangitis was developed bacterobilia was also higher (RR 2,53, CI 95% 1,04-6,1); but when patients were operated while receiving antibiotic treatment the rate of bacterobilia was lower (p=0,05). Age, sex, BMI, alcoholism, smoking, diabetes, inmunosupressive treatment, level of bilirubin, hemoglobin or albumin showed no difference. The presence of bacterobilia was not associated to higher rates of wound infection or other postoperative complications. In multivariate analysis only being operated under antibiotic treatment showed statistical significance (p= 0,041).
Conclusion: Instrumentation of the biliary tree prior surgery should be performed in selective patients. Surgery during antibiotic treatment is feasible and reduces the risk of bacterobilia.
PB06-45 Mass-forming Xanthogranulomatous Cholecystitis Masquerading as Invasive Gallbladder Cancer with a False-positive Result on PET Leading to Extensive Surgical Resection
Hyuk Jai Jang, Korea, Republic of

H.J. Jang
Surgery, Ulsan University. Gangneung Asan Hospital, Gangneung, Korea, Republic of

Xanthogranulomatous inflammation of gallbladder wall can extend and infiltrate adjacent organs which can be mistaken for malignancy on preoperative investigations and, intraoperatively, often leads to extensive surgical resections. Only the histopathologic examination of the specimen allows correct diagnosis. We hereby review clinicopathologic findings of a case which underwent extensive surgeries on clinical, radiological and intraoperative suspicion of gallbladder carcinoma which turned out to be xanthogranulomatous cholecystitis. Xanthogranulomatous inflammation extended into liver, duodenum and colon in our case. A 74-year-old woman was admitted to our hospital for right upper quadrant and epigastrium discomfort and diagnosed as gallbladder carcinoma by ultrasonography, computed tomography and fluorine-18 fluorodeoxyglucose positron emission tomography ( FDG-PET).
Serum CA19-9 (62.6 U/ml) were elevated. We diagnosed the lesion preoperatively as a gallbladder carcinoma with direct invasion to the liver bed and colon. We performed subsegmentectomy of the liver S4a + S5 and lymph node dissection of the hepatoduodenal ligament with segmental colon resection.
Several reports have demonstrated that FDG-PET is useful in differentiating between benign and malignant lesions in the gallbladder. However, there is a limitation in the ability of FDG-PET to differentiate between inflammatory and malignant lesions. We herein present a case of xanthogranulomatous cholecystitis misdiagnosed as gallbladder carcinoma by ultrasonography and computed tomography. FDG-PET also showed increased activity. In this case, FDG-PET findings resulted in a false-positive for the diagnosis of gallbladder carcinoma.
PB06-46 Are We Using the Adequate Antibiotic Prophylaxis in Biliary Surgeries?
Francisco Juan Mattera, Argentina

M.L. Del Bueno, M. Chahdi Beltrame, J.G. Cervantes, J.P.S. Duran Azurduy, M. Poupard, M.E. Lenz Virreira, E.G. Quiñonez, F.J. Mattera
Hepatobiliar Surgery and Liver Transplantation, Hospital el Cruce, Argentina

Introduction: Patients undergoing hepato-pancreato-biliary surgery frequently have preoperative cholestasis and ERCP or preoperative biliary drainage may be necessary. This is a known higher risk for bacterobilia and leads to a higher risk for developing surgical site infections. Standard antibiotic prophylaxis may not be totally effective in this population.
Methods: Retrospective analysis including biliary surgeries from 2014 to 2019. Bile culture, antibiotic prophylaxis and postoperative complications were analyzed. Statistical analysis was made using Fisher and chi2. Differences were considered statistically significant at
P < 0.05.
Results: 86 patients underwent biliary surgery. Surgical bile duct injuries (34.9%) and post liver transplant biliary strictures (14.0%) were the most frequent diagnosis. Only 24 patients (27.9%) underwent preoperative percutaneous biliary drainage and 47 patients (54.6%) had at least one preoperative ERCP. Hepatojejunostomy was the most frequent surgery (75,6%). Bacterobilia was confirmed in 52%; the most common bacteria were Escherichia spp (55%) and Klebsiella spp (42%). Antibiotic most common prophylaxis was cefazolin (23.3%) or Piperacillin-Tazobactam (23.3%). Prophylaxis was only effective in 21% of Bacterobilia. Postoperative complications were more frequent when prophylaxis was inadequate (p=0,015). However, when type of complication was analyzed we found no difference; even though wound infection was higher when prophylaxis was inadequate it was not statistically significant.
Conclusion: Bacterobilia can be high specially when previous instrumentation of the biliary tree has been performed. Antibiotic prophylaxis should be escalated when bacterobilia is suspected to diminish risk of postoperative complications.
PB06-47 Ascaris Lumbricoides as a Cause of Obstructive Jaundice. When the Nematode Outdoues Fiction
Samuel Arnulfo Pimentel Melendez, Mexico

S.A. Pimentel Melendez1, F. Arcila Briceno2, E. Jimenez Chavarria3, H.F. Noyola Villalobos3
1Digestive and Endocrine Surgery, IMSS High Specialty Medical Unit No 25. CMNN, Mexico, 2General Surgery, Hospital Agustin Ohoran, Mexico, 3HPB Surgery, Hospital Central Militar, Mexico

Lumbricoid ascariasis, is the most common helminth in humans.It is a cylindrical worm, humans acquires it by ingesting its eggs, which is found in contaminated areas. It is initially housed in the duodenum and small intestine, from where it can reach other sites. Such as the bile duct, where it can cause bile duct obstruction. Since its frequency is relatively low, we present a case of obstructive jaundice due to ascariasis.
The patient, a Female of 15 years, begins with sudden pain in the right hypochondrium, as well as changes in coloration in teguments until reaching jaundice,Managed medically without improvement,she was sent to our unit. Upon with septic shock, pain in the right hypochondrium, with no evidence of peritoneal irritation. Biliary USG, with intrahepatic dilatation of BD, as well as double rail image in bile duct. CT scan with a bile duct in the intrapancreatic portion, as well as an elongated, hyperdense tubular image. ERCP is performed, finding dilated bile duct of with filling defects in distal parth compatible with stones and a long filling defect suggestive of ascariasis, a wide sphincterotomy was performed, and several small stones of approx. 5 to 10 mm, two of 12 mm and an adult Ascaris were removed. 72 hours later laparoscopic cholecystectomy is performed without eventualities, and patient was discharged the next day.
Biliary ascariasis is an entity that represents 3.5% of the causes of jaundice, however it should be suspected in entities where the prevalence of the nematode is high.
[aarci]
PB06-48 Surgical Treatment for Serious Complications of Portal Biliopathy
Gabriela Ochoa, Chile

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

Introduction: Surgical treatment for complication of portal biliopathy is an exception. It implies a high risk of bleeding given the prominent collaterals present in the hepatoduodenal pedicle secondary to portal cavernomatosis.
Methods: Descriptive study of 4 patients who presented serious complications linked to portal biliopathy that required surgical management within the Clinical Hospital of Universidad Católica.
Results: Woman 59 years, with necrohemorrhagic pancreatitis (1996), biliodigestive bypass (2001) and portal cavernomatosis (2004) was presenting repeated episodes of hemobilia, one with hypovolemic shock. A Warren's shunt was tried (2005), but it failed. Then, a choledochal devascularization and hepatic-jejunal re-anastomosis intervention was made. Man 57 years, with HIV positive and serious pancreatitis (2007), developed portal thrombosis post inflammatory and cavernomatosis and presented repeated cholangitis. Roux-en-Y reconstruction was made (2012). Woman 47 years, with V Leiden factor deficit and portal cavernomatosis (2012), presented repeated cholangitis. After multiple endoscopic stent treatments, given recurrence of cholangitis and jaundice, a Roux-en-Y biliary reconstruction was performed (2015). Man 47 years, with neonatal trombosis and cavernomatosis for omphalitis, had portal devascularization surgery made at 7 and 14 years old, he had repeated cholangitis despite multiple endoscopic attempts. Roux-en-Y was performed. All anastomosis was made in biliary conducts with multiple collateral veins that were handled with bipolar coagulation, ligatures and stiches. On the long term, none repeated episodes of hemobilia or cholangitis.
Conclusion: The surgery could be a definite solution for portal biliopathy complications. However, it has only been made for selective cases because it implies high complexity and risk.
PB06-49 Management of Bouveret´s Syndrome
Roheena Panni, United States

R. Panni1, M. Doyle2, W. Chapman2, A. Khan2
1Surgery, Washington University in Saint Louis, United States, 2Hepatobiliary and Transplant Surgery, Washington University in Saint Louis, United States

Introduction: Bouveret's Syndrome is defined as gastric outlet obstruction from a large gallstone in the duodenum through a cholecystoduodenal fistula. It is a rare variant of gallstone ileus and accounts for less than 3% of all gallstone ileus cases. We present a case of cholecystoduodenal fistula with 4cm stone causing obstruction in duodenum in the setting of malrotation.
Case presentation: 67 year old Caucasian female with history of symptomatic cholelithiasis presented with acute onset nausea/vomiting and oral intolerance for 5 days. She had mild epigastric and right upper quadrant tenderness on examination. CT revealed cholecystoduodenal fistula with one large stone (4 cm) impacted in duodenum causing gastric outlet obstruction with malrotation. Endoscopy was not attempted due to the size of stone and presence of malrotation. Patient was taken to OR for exploratory laparotomy and stone removal. Large cholecystoenteric fistula was clearly identified and duodenotomy was performed distal to obstructing stone in the 3rd portion of duodenum, stone was extracted and duodenum was closed transversely. She was deemed too high risk for cholecystectomy and fistula repair given age and co-morbidities. Post op course unremarkable. Upper GI gastrograffin series demonstrated no leak post operatively.
Doing well on last follow up.
Discussion: Patients with Bouveret's syndrome have high mortality rate(12-27% due to delay in diagnosis, advanced age and comorbidities. Endoscopic stone retrieval/fragmentation is often the first step in treatment and surgical treatment is required in upto 91% of patients and considerable debate remains over optimal treatment option.
[Management of Bouveret's syndrome]
PB06-50 Malrotation of Liver and Porta Hepatic Structures Encountered during Laparoscopic Cholecystectomy- Case Report
Rajesh Yadav, India

A. Lambe1, R. Yadav2, M. Begani1, A. Mohd1
1General Surgery, Bombay Hospital Institute of Medical Sciences, India, 2HPBI and General Surgery, Bombay Hospital Institute of Medical Sciences, India

Ever since the start of study of anatomy there have been numerous anatomical variations or aberrations that have been reported for gall bladder, cystic artery, cystic duct, hepatic artery, common bile duct and portal vein. Performing surgeries with laparoscope provides magnified image, thereby allowing a better vision and understanding of the local anatomy of the gall bladder, calot's triangle and porta hepatis. Cholecystectomy requires keen observation and meticulous dissection. Even the most experienced surgeons have encountered complications during laparoscopic cholecystectomy owing to the anatomical variations. Here is a case report of a 36 year old lady presenting with acute calculous cholecystitis. She was taken up for laparoscopic cholecystectomy. Only the fundus of the gall bladder was seen. Gall bladder was to the left of falciform ligament. During dissection there was sudden gush of blood which could not be controlled, hence converted to open surgery. There was malrotation of the liver causing falciform ligament to be at the right of gall bladder. There was malrotation at the porta with portal vein anterior to common bile duct and hepatic artery and anomalous portal vein being the site of bleeding. Unpredictability of the structures at porta and gall bladder anatomy is a predicament requiring furthermore understanding.
PB06-51 Management of Acute Disease in the Remnant Gallbladder: The Effectiveness of Repeat Laparoscopy
Ileana Horattas, United States

I. Horattas, A. Guzowski, A. Noaman, J. Gabra
Cleveland Clinic Akron General, United States

Introduction: Subtotal cholecystectomy has become a widely accepted alternative for patients presented with acute cholecystitis resulting in significant inflammation and anatomic distortion. Recurrent cholecystitis of the remnant gallbladder is an accepted complication of this procedure. International studies have shown completion cholecystectomy to be the definitive management of recurrent cholecystitis. Few investigators in the United States have focused on management of this scenario, and to this point open surgical approach has been recommended.
Methods: Cholecystectomies undertaken by one hepatobiliary surgeon over a two-year period from 2017-2019 were reviewed. Cases of patients with previous cholecystectomy who then presented with acute cholecystitis and underwent laparoscopic completion cholecystectomy were compiled and reviewed to determine interval from initial cholecystectomy, operative time, use of intraoperative cholangiography, use of intraoperative indocyanine green (ICG), placement of drain, and total length of hospital stay (LOS).
Results: Seven patients met inclusion criteria. The mean interval from initial cholecystectomy was 22 months (range 3-89 months with one patient presenting an unknown length of time from initial operation). Mean operative time was 119 minutes (range 79 minutes to 141 minutes). Five patients had an intraoperative cholangiogram and one case was completed with intraoperative ICG. A drain was left at the completion of three out of seven cases. Average LOS was less than one day (range 0-2) with three patients discharged in good condition post-operative day 0.
Conclusions: Laparoscopy is a safe and effective approach to completion cholecystectomy for patients with recurrent cholecystitis that avoids an open surgical procedure.