General HPB 
PG03 General HPB: Education (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PG03-02 Shortening Surgical Training through Robotics: A Randomised Controlled Trial of Laparoscopic versus Robotic Surgical Learning Curves
Tamara Gall, United Kingdom

T. Gall1, W. Alrawashdeh2, S. White2, L. Jiao1
1Imperial College London, United Kingdom, 2Freeman Hospital, United Kingdom

Objective: To compare laparoscopic and robotic training.
Background: Minimally invasive surgery is the gold standard technique for many operations. Laparoscopic training has a long learning curve. Robotic solutions may shorten the training pathway.
Methods: Surgical trainees (ST group) were randomised to receive 6 hours robotic or laparoscopic simulation training. They then performed cholecystectomy; continuous suture closure of a gastrostomy and interrupted suture closure of small bowel in cadaveric specimens. Medical students (MS group) had two hours robotic or laparoscopic simulation training followed by interrupted suture closure of a gastrostomy. The Global rating scale score (GRS), number of suture errors and time to complete each procedure was recorded.
Results: The median GRS score for the ST group was better after robotic training (total GRS score 27.00 +/- 6, n=10) compared to laparoscopic training (18.00 +/- 5, n=10, p< 0.001). There were less errors made for the robotic group compared to the laparoscopic group for continuous suture (7.00 +/- 5 and 22.25 +/- 5 respectively, p< 0.001) and interrupted sutures (8.25 +/- 4 and 29.50 +/- 8 respectively, p< 0.001). For the MS group, the robotic group completed 8.67 interrupted sutures with 15.50 errors in 40 minutes, compared to 3.50 sutures with 40.00 errors in the laparoscopic group (p< 0.001). Fatigue and physical comfort levels were better after robotic operating compared to laparoscopic operating (p< 0.001) for both groups.
Conclusions: The acquisition of surgical skills in surgical trainees and the surgically naive takes less time with a robotic compared to laparoscopic platform.
PG03-04 Classical Music Therapy and Pre Operative Anxiety in the Operating Room Fatmawati Central General Hospital
Eka Sukma, Indonesia

E. Sukma, A. Nugroho
HPB Unit, Digestive Surgery, Fatmawati Central General Hospital, Indonesia

Surgery is a traumatic experience that threatens everyone who will undergo surgery. This anxiety is usually motivated by the threat of death, pain, bleeding. Several studies have found that 75% -85% of patients are anxious before surgery and thus require nursing intervention in the form of providing health education, relaxation training techniques, applying spiritual practices that are usually performed by patients such as praying, singing or listening to spiritual songs. This study aims to determine the success rate of anxiety reduction in the application of classical music therapy. This research is cross sectional. This study uses a quasi-experimental method with one group pre-test and post-test without control group. The sample in this study were 20 patients who were going to undergo surgery in the preparation room of Fatmawati Hospital. Data collection tools using the HARS (Hamilton Anxiety Ratting Scale) questionnaire. The results of the study before being given an intervention have anxiety categories of mild (10%), severe (70%). Whereas after the intervention was given, it had mild (80%), severe (5%) anxiety. It can be concluded that there is a significant influence of patient anxiety before and after the administration of classical music therapy. It is expected that the results of this study can be applied as an SOP for the application of classical music therapy while the patient is in the preparation room of the Fatmawati General Hospital.
PG03-05 ANZHPBA Post-Fellowship Training in HPB Surgery: A Comprehensive Review from the First 10 Years
Andrew Gray, Australia

A. Gray1, R. Gaszynski2, N. Merrett2, J. Slater3, D. Cavallucci4, T. Wilson5, C. Apostolou2
1Department of Upper GI & Hepatobiliary Surgery, Monash Medical Centre, Australia, 2Department of Upper Gastrointestinal Surgery, Bankstown-Lidcombe Hospital, Australia, 3Department of General Surgery, Royal Hobart Hospital, Australia, 4Royal Brisbane and Women's Hospital, Australia, 5Division of Surgery, Flinders Medical Centre, Australia

Introduction: The Australian and New Zealand Hepatic, Pancreatic and Biliary Association (ANZHPBA) post-fellowship training program stands in the unique position of being one of only two worldwide to formalise post-fellowship education of hepatic, pancreatic, and biliary (HPB) surgeons. Over the ten years since its inception, the program has become the sought-after credential in the armament of aspiring HPB surgeons throughout Australia and New Zealand. Despite this, no formal review process has occurred to allow previous trainees to reflect on the training they received.
Method: The ANZHPBA endorsed the distribution of an electronic survey to the 50 trainees who had completed their training. The survey consisted of 41 questions describing the experience of HPB training during their fellowship. It was available for completion on-line between May and November, 2019.
Results: 39 respondents completed the survey resulting in a 78% response rate. Operative experience and surgical teaching during training was considered positive by 80% and 87% respectively. 64% of respondents felt adequately prepared for consultant practice upon completion of the program, with 85% currently employed as an HPB surgeon, and 67% working in a tertiary-level centre. Just over half of the respondents felt there could be changes made to the training program with the most frequent suggestions to increase the length of training and modernising the assessment and feedback process.
Conclusions: The ANZHPBA fellowship provides a surgical education that trainees describe as adequate for consultant HPB practice, with the majority of graduates employed in that capacity following completion of the program.
PG03-07 Celiac Artery Aneurysm and Pseudoaneurysm Caused by Median Arcuate Ligament Syndrome (MALS) with Different Presentation: A Case Series
Yiing Yee Gan, Malaysia

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

Introduction: The median arcuate ligament syndrome (MALS) is a rare vascular disorder caused by an extrinsic compression of the celiac artery from the median arcuate ligament.It is associated with aneurysmal dilatation due to compression. Although it usually comes with the classical triad of chronic abdominal pain, weight loss and epigastric bruit , it still manifests a wide variety of symptoms.
Method: We observed 3 cases of celiac trunk aneurysm associated with this condition presented to us initially with different symptoms and MALS were detected by computed tomography scan.
Case 1: a 67 year old lady presented with epigastric pain underwent CT showed superior and inferior pancreaticoduodenal artery aneurysm. Successful angioembolisation of aneurysm done and proceeded with release of median arcuate ligament.
Case 2: A 56 year old gentleman presented with symptoms of gastric outlet obstruction, CT scan showed duodenal mass with GDA pseudoaneuryms, Whipple procedure was performed.
Case 3. A 51 year old gentleman presented with obstructive jaundice and was diagnosed with pancreatic head carcinoma, proceeded with Whipple procedure, only to discover common hepatic and superior anterior pancreaticoduodenal artery pseudoaneurysm post surgery via digital subtraction angiography.
Conclusion: Aneurysms associated with MAL syndrome is quite rare and may present with different symptoms at time of diagnosis. Angioembolisation should be the treatment of choice and followup for recurrence is warranted.
PG03-09 HPB and Transplant Operative Experience among New Zealand General Surgery Trainees
Alistair Rowcroft, Australia

A. Rowcroft1, D. Joh2, S. Pandanaboyana3, B. Loveday1,4,5
1General Surgery, Royal Melbourne Hospital, Australia, 2University of Auckland, New Zealand, 3HPB and Transplant Unit, Freeman Hospital, United Kingdom, 4Surgical Oncology, Peter MacCallum Cancer Centre, Australia, 5Surgery, University of Auckland, New Zealand

Subspecialty surgery experience during General Surgery training in Australasia is influenced by many factors including duration of training, training location, and the introduction of post-fellowship training programs. Experience in hepato-pancreato-biliary (HPB) and transplant surgery is part of the general surgery curriculum, although trainee experience in these subspecialties has not been quantified in this region, which is relevant to post-fellowship training programs. Therefore, the aim of this was to quantify the HPB and transplant operative experience of New Zealand (NZ) General Surgery trainees.
Operative logbook data were analysed for all NZ trainees from 2013 to 2017, including procedures categorized as pancreatic, biliary, hepatic and transplant surgery only. The number of cases within each category were used to model the cumulative operative experience over a five year training program.
During the study period 118 trainees (303 trainee years) recorded 15,662 HPB and transplant procedures. Of these, 13,838 (88.4%) were cholecystectomies (mean cumulative experience 219.3 cases). Excluding cholecystectomy, trainees had a mean cumulative experience of 5.7 biliary, 7.5 pancreatic, 8.1 liver, and 4.2 transplant procedures during their training. Transplant experience was predominantly access for peritoneal dialysis (228/260, 86.7%), with cumulative transplant experience otherwise reaching 0.47 procedures over five years.
Exposure to HPB and transplant surgery during General Surgery training in NZ is limited beyond cholecystectomy. Expectations of first-year Fellows undertaking further HPB or transplant training must reflect these limitations.
PG03-10 Association of Preoperative Sarcopenia with Postoperative Complications Following Hepato-pancreato-biliary Cancer Surgery
Narendra Maharjan, Nepal

N. Maharjan1, B. Ghimire2, P. Kansakar2, R.S. Bhandari2, P.J. Lakhey2
1GI and General Surgery, Tribhuvan University/Institute of Medicine, Nepal, 2Tribhuvan University / Institute of Medicine, Nepal

Introduction: Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength with a risk of adverse outcomes such as physical disability, poor quality of life and death. At present, perioperative mortality has been decreased, but morbidity is still high. Sarcopenia is independently associated with poor prognosis across a wide range of oncology settings
Methodology: This is a prospective observational study of 31 cases from 15th April 2019 to 14th Oct 2019 conducted in Department of GI and General Surgery, TUTH, Kathmandu. All patients who underwent elective HPB cancer surgery at TUTH were included. Preoperative sarcopenia was calculated as skeletal muscle index = (skeletal muscle area at L3 in CECT) / (height in meter) 2. The main aim was to determine association of preoperative sarcopenia with major postoperative complication.
Results: The demographic characteristics (age, sex, performance status, albumin, BMI) of patients with and without sarcopenia were similar. The patients underwent various types of operation like: extended cholecystectomy, right extended hepatectomy and Whipple's procedure. The postoperative major complications were significantly higher in sarcopenic patients (p = 0.0001). Sarcopenic patients also had longer hospital stay.
Conclusion: Preoperative sarcopenia is associated with major post-operative complications and longer hospital stay following hepato-pancreato-biliary cancer surgery.
PG03-11 The Feasibility and Benefits of in Vivo Swine Training Model for Laparoscopic Liver Resections among General Surgery Residents
Nasser Abdul Halim, France

C. Popa1,2, N. Abdul Halim3,4, C. Pestean4,5, L. Oana5, N. Al Hajjar1
1General Surgery, Regional Institute of Gastroenterology and Hepatology, Romania, 2Training and Research Centre “Prof. Dr. Sergiu Duca”,, Romania, 3General Surgery, Beilinson Hospital, Israel, 4Training and Research Centre “Prof. Dr. Sergiu Duca”, Romania, 5Faculty of Veterinary Medicine, USAMV, Romania

Background: Laparoscopic liver resections (LLR) are gaining popularity worldwide, however, a proper and efficient training model is lacking, mainly for residents and young surgeons. The aim of our study is to assess the feasibility and benefits of a “step-by-step” training model in LLR created for residents as part of a continuous training program.
Methods: From May 2017 to October 2018, 30 residents who previously participated in laparoscopic surgery workshops at “Prof. Sergiu Duca” training centre, Cluj-Napoca, Romania, participated in a “step-by-step” guided LLR protocol workshop on swine (Stage 1) aiming to analyse its feasibility. The protocol consisted of performing cholecystectomy, liver mobilization, minor and major resections. Their performance results in terms of operative time, blood loss, conversion, trainers' intervention and intraoperative mortality, were recorded. Twenty-four of these residents (6 dropped out as they turned seniors) were later compared to 24 senior surgeons who neither followed the protocol nor performed LLR previously (Stage 2), and to another 24 residents who weren't part of a training program but followed the protocol (Stage 3), aiming to assess its' benefits.
Results: All residents fully completed the surgical procedures. Trained residents obtained better operative times and less blood loss compared to senior surgeons (p< 0,017), however, the remaining parameters were comparable. When compared to non-trained residents, the trained ones had significantly better results only in operative times (p< 0,001).
Conclusion: A continuous LLR “step-by-step” training program on swine for residents is feasible. It can be successfully applied with clear benefits on practical skills.
PG03-12 Robotic Sugery in HBP Field: Single Center Experiences
Hee Chul Yu, Korea, Republic of

J.D. Yang1, H.C. Yu2, S.W. Ahn1, S.E. Hwang3
1Surgery, Chonbuk National University Hospital, Korea, Republic of, 2Surgery, Jeonbuk National University Hospital, Korea, Republic of, 3Daesion Sun Hospital, Korea, Republic of

Backgrounds: The robotic platform might offer superior ergonomics over other minimally invasive approaches.
the use of a robotic system potentially broadens indications for minimally invasive surgery in HBP field.
However, the increased time required for instrument set-up, operations, and surgical training are perceived as major drawbacks. We report our experience at Chonbuk national medical center in HBP field.
Methods: From September 2017 to November 2019, all consecutive patients(n=112) who underwent robotic surgery were retrospectively analyzed. Variables of interest for this study were patient demographics, operative times for the procedure and morbidities.
Results: Among 112 patients, 98 from cholecystectomy, 7 from hepatectomy, 6 from pancreatectomy and 1 from bile duct resection. The mean age of recipients was 45.2 years with range of 15-68 years.. The Hepatectomy was performed in 2 HCC cases and 5 benign disease cases,
The pancreatectomy(distal 3, pancreaticoduodenectomy 3) and bile duct resection were performed in benign diseases.
The mean docking and operating times were 8.7(83) mins in cholecystectomy, 14(289)mins in hepatectomy , 28(368)mins in distal pancreatectomy, and 25 (590)min in pancreticoduodenectomy
Total numbers of open and laparoscopic conversion are 2 cases cause of sever adhesion.
Postoperative complications were bile leaks (1 case in bile duct resection) and cholangitis (1case in cholecystectomy).
Conclusion: In our results, robotic assisted laparoscopic surgery in HBP filed is feasible and safe for a variety of procedures.
PG03-14 An International Hepatobiliary Multidisciplinary Team Meeting: A Case for Its Perpetuation
Ian Goh, Australia

I. Goh, G. Foo, M. Siriwardhane
Hepato-Pancreatico-Biliiary/General Surgery, Mater Health Services, Australia

Introduction: Multidisciplinary team meetings (MDTs) are integral to modern surgical oncology. With multiple specialists coming together to discuss patient care on a case-by-case basis, they have been shown to improve patient outcomes.
The global cancer burden appears to be shifting to less developed countries - patient load is high, resources are low, and clinicians often work in isolation, with little access to multidisciplinary care teams. With the use of videoconferencing, international MDTs can take place over great geographical distances, providing insight, exchange of medical knowledge, protocols and guidelines amongst colleagues.
Methods: We implemented a unique model for an international hepatobiliary MDT in order to improve services in developing nations and enhance our own management of complex cases.
3-monthly meetings were conducted by a Chairperson at a coordinated time with 7 Hepatobiliary units worldwide contributing simultaneously. A secure web-based platform was used for case presentations.
Results: 6 MDTs have been successfully coordinated despite the 5 different time zones between the 7 different institutions (Table 1.). More than 40 patients have been discussed. Since overcoming the problems of internet connections and technical issues, the participating institutions enjoyed complex case-based as well as building the global peer group that has resulted in skills workshops.
Conclusion: We show it is possible to continually coordinate and implement an international hepatobiliary MDT meeting. Robust discussion, improvement in evidence-based practice in developing countries and building an international peer group were byproducts of such a process.
Participating LocationsLocal Time
Brisbane, Australia2100H
Yangon, Myanmar1730H
Kandy, Sri Lanka1630H
Colombo, Sri Lanka1630H
Manchester, U.K.1100H
Edinburgh, Scotland1100H
Dallas, U.S.A0600H
[Table 1.]
PG03-15 Albumin as a Predictor of Outcome in Patients Undergoing Gastrointestinal (GI) and Hepato-pancreato-Biliary (HPB) Operations: A Prospective Bi-cohort Study
Samrat Ray, India

S. Ray1,2, N. Mehta1, P. Chugh3, V. Mangla1, A. Yadav1, S. Nundy1
1Surgical Gastroenterology and Liver Transplantation, Sir Ganga Ram Hospital, India, 2Kanti Devi Medical College and Hospital, India, 3Research and Biostatistics, Sir Ganga Ram Hospital, India

Introduction: Serum albumin is a readily available biochemical parameter, shown to have a high positive predictive value for surgical complications and mortality. We aimed to study the relationship of pre-operative serum albumin levels with outcome in GI and HPB surgical patients.
Methods: All consecutive patients undergoing GI and HPB surgeries in geographically different two cohorts of population A and B (SGRH and KDMC respectively) were collected between 2019-2020 by the two principal investigators. The serum albumin levels were arranged in 4 quartiles and the correlation and association of the levels with the outcome variables (length of post-op stay, ICU stay, Clavien-Dindo grading and mortality) and other demographic and pre-operative variables were studied using ANOVA and Kruskall-Wallis tests.
Results: There were a total of 602 patients in cohort A (M:F=1.5:1) and 172 patients in cohort B (M:F=0.8:1). The median (IQR50) serum albumin in cohort A was 3.3 gm/dl and 3.4 gm/dl in cohort B. There was a strong association of serum albumin levels with age, body mass index (BMI), Hemoglobin levels, bilirubin levels and nature of disease (benign or malignant) in both the cohorts of population (p< 0.001). There was no significant association of outcome variables with albumin levels in both the cohorts. However, there was trend towards lower incidence of major complications (CD>/=III) in the higher quartiles of albumin (p=0.03).
Conclusion: Low pre-operative serum albumin levels could be a simple marker to predict the incidence of major complications in GI and HPB surgical patients of varying geographic ethnicity.
PG03-17 Delayed Presentation for Oncological Care among Patients with Hepato-pancreato-Biliary Cancers in Ile-Ife, Nigeria
Funmilola Wuraola, Nigeria

F. Wuraola1,2, O. Olasehinde1,2, O. Alatise1,2, A. Adisa1,2, O. Arowolo1,2
1Surgery, Obafemi Awolowo University, Nigeria, 2Obafemi Awolowo University Teaching Hospital Complex, Nigeria

Introduction: Hepato-pancreato-biliary cancers are associated with high mortality rate. It been projected that cancer incidence will rise by 70% in developing countries. Cancer mortality rate is high in Nigeria also late presentation is then norm. This study aims to identify the various factors responsible for delay by assessing both patients and health system factors.
Methods: This is a cross-sectional survey of all patients presenting with hepato-pancreato-biliary cancers in Ile-Ife. Socio-demographic details were documented in a proforma while an interviewer administered questionnaire were administered. Patients delay is defined as the time between identifying the first symptom and presentation at health facility while system delay is time from presentation to diagnosis and treatment.
Data were analysed using Statistical Package for Social Sciences version 24.
Results: One-hundred and twenty-three patients presented with hepato-pancreato-biliary cancers within three years. About 57% male and 43 females, 77.7% presented with stage III and IV disease. Patient delayed was found in 78.8% of cases, self-medication and financial constraints been the commonest reasons. 73.4% presented at primary health facility first before referral to tertiary hospitals. The system delay is seen in 37% of patients with mean time interval from diagnosis to treatment been 22.67days.
Conclusion: Delay in presentation is common leading to late presentation with resultant high morbidity and mortality.
PG03-18 Palliative Management of Terminal Stage Hepatobiliary Pancreas Malignancy: Hospice Care Perspective in the Era of POLST
Jin Lim, Korea, Republic of

J. Lim1, J.-M. Lee2
1Department of Internal Medicine, Seoul National University Hospital, Korea, Republic of, 2Department of Surgery, Seoul National University Hospital, Korea, Republic of

Introduction: Hepatobiliary and pancreatic (HBP) malignancy remains a highly lethal disease, with nearly 70-80% of patients presenting with metastatic or locally advanced disease. Recent chemotherapy for metastatic pancreatic cancer (FOLFIRINOX) improves median survival. Even though this regimen increased survival, since the implementation of the POLST in Korea, paradigm it began to change. We described and analyzed the status of POLST and treatment in the real world and discuss about principle of palliative care focused on HBP malignancy.
Method: Between February 2018 and December 2019, we reviewed the terminal stage hepatobiliary and pancreas cancer patient who have already agree with POLST retrospectively.
Results: Total 158 patients of HBP malignancy were analyzed. The mean age was 65 years and proportion of hepatocellular carcinoma (HCC), cholangiocarcinoma and pancreatic cancer was 20.2% vs. 37.9% vs 41.9%. Symptoms were reported differently according to the types of cancer, In the case of hepatocellular carcinoma, 70% of patients suffered from abdominal distension due to malignant ascites, and 84% of patients of biliary tract cancer had jaundice and itching sense. Opioid analgesics were significantly used common in 96% of pancreatic cancer. Patients with HCC and biliary tract cancer had a high rate of treatment such as PTBD and PCD even after POLST.
Conclusion: In the era of POLST, palliative treatments have become a major issue. Depending on the symptoms associated with the type of cancer, appropriate treatment should be applied and it will be a good way to improve QOL in terminal cancer patients.