Poster
General HPB 		  
PG04 General HPB: Evidence Based Medicine (ePoster) 
Selection of ePoster Presentations from Abstract Submissions
PG04-01 Pre Morbidity and Mortality Hospital Stay Independently Predict Post Operative Morbidity in Gastrointestinal and Hepatobiliary Surgery: A Prospective Analysis
Bhavin Vasavada, India

B. Vasavada, H. Patel
Hepatobiliary and Liver Transplantation, Shalby Hospitals, India

Aim: Aim of study was to study effect of perioperative hospital stay before onset of complications on subsequent morbidity and mortality.
Materials and methods: We evaluated all the patients operated for gastrointestinal and hepatobiliary surgery between April 2016 and October 2019 prospectively for morbidity and mortality. We evaluated various factors responsible for morbidity and mortality including pre-morbidity and pre-mortality hospital stay. Morbidity defined as clavien dindo grade 3 and 4 complications. Statistical analysis was done using SPSS version 23. Categorical factors were evaluated using chi square test, continuous factors using Mann-Whitney U test. Multivariate analysis done using logistic regressing method.
Results: Total 305 patients were evaluated prospectively. On univariate analysis Open surgery, prolonged pre morbidity hospital stay, blood products used, higher CDC grade of surgery, Higher ASA grade predicted 90 days morbidity. On multivariate logistic regression analysis only higher pre hospital stay predicted the morbidity. (p=0.029).On univariate analysis Higher pre morbidity or mortality hospital stay was not associated with mortality. However, Morbidity independently predicted mortality. (p=0.017).
Conclusions: Pre hospital stay is significantly associated with higher complication rates and morbidity. Unnecessary hospital stay should be avoided.
PG04-03 Modified Postoperative Pancreatic Fistula Classification System: Proposal and Clinical Validation
Sung Hyun Kim, Korea, Republic of

S.H. Kim, H.K. Hwang, K.S. Kim, W.J. Lee, C.M. Kang
Hepatobiliary and Pancreatic Surgery, Yonsei University College of Medicine, Korea, Republic of

Background: Postoperative pancreatic fistula (POPF) is important complication influencing postoperative outcomes. Although the classification by the International Study Group on Pancreatic Fistula (ISGPF) is generally used to describe POPF, it can be improved.
Methods: The medical records of 528 patients who underwent pancreatectomy from 2011 to 2015 in a single center were retrospectively reviewed. The patients were divided into groups according to a modified POPF (mPOPF) classification. (No POPF: same as ISGPF, BL: previous BL patients except those who had a surgical drain over 2 weeks, B1: patients with clinically relevant change, but no need for interventional therapy (IT), B2: patients with IT, C: previous Grade C without mortality cases, D: mortality cases due to POPF) Postoperative outcomes were analyzed in comparison with the previous ISGPF POPF system.
Results: mPOPF showed significantly improved clinical and economic relevance according to the grades (length of hospital stay (day); No POPF vs. BL: 17 [13-23] vs. 14 [11-18], p=0.004, BL vs. B1: 14 [11-18] vs. 20 [15-26], p< 0.001, B1 vs. B2: 20 [15-26] vs. 34 [25-38], p< 0.001, B2 vs. C: 34 [25-38] vs. 47 [32-62], p=0.005, C vs. D: 47 [32-62] vs. 71, p=0.087, cost variation; No POPF: reference, BL: + 1%, B1: + 9%, B2: + 38%, C: + 90%, D: + 161%, p< 0.001).
Conclusions: The mPOPF classification could discriminate the severity of POPF better in terms of clinical relevance and economics to complement ISGPF POPF. Further external validation in the form of a study is necessary.
[Flow chart for the mPOPF classification]

N = 528No POPF 292 (55.3%)BL 67 (12.7%)Grade B1 107 (20.3%)Grade B2 37 (7.0%)Grade C 22 (4.2%)Grade D 3 (0.6%)p value
POPF related re-admission0 (0.0%)0 (0.0%)0 (0.0%)5 (13.5%)6 (27.2%)2 (66.7%)<0.001
Drainage duration (day)10 [7-13]8 [7-10]12 [9-15]20 [15-28]21 [13-36]9<0.001
LOS (day)17 [13-23]14 [11-18]20 [15-26]34 [25-38]47 [32-62]71<0.001
Cost (103$)12.1 [10.3-14.6]12.2 [9.4-13.8]13.2 [11.3-16.2]16.6 [13.8-19.5]22.7 [19.8-28.9]31.6<0.001
Cost variation(reference)+ 1%+ 9%+ 38%+ 88%+ 161% 
[Clinical and economic outcome measures according to the mPOPF classification]
PG04-04 A Single Center Prospective Randomized Study for Comparison of Water Jet Dissector and Ultrasonic Aspirator in the Division of the Liver Parenchyma during Laparoscopic Resection
Mikhail Efanov, Russian Federation

M. Efanov, I. Kazakov, R. Alikhanov, A. Vankovich, A. Koroleva, N. Elizarova, N. Kulikova
Moscow Clinical Scientific Center, Russian Federation

Introduction: To date, there are no prospective randomized studies that have studied the safest and most feasible method of liver parenchyma transection in laparoscopic liver resection (LRR).We aimed to compare the short-term results of two methods of liver parenchyma transection during LLR in a prospective, randomized trial.
Methods: Two groups were compared after LLR with and ultrasonic surgical aspiration system (CUSA) and waterjet dissector (WJD). The samples size of 30 patients was calculated for 90% statistical power. Randomization in each arm was performed using envelopes. Inclusion criteria were benign liver tumors (hemangioma, focal nodular hyperplasia, hepatocellular adenoma, hydatid echinococcosis [only with total pericystectomy]) and malignant tumors (colorectal cancer metastases, hepatocellular carcinoma, intrahepatic cholangiocarcinoma). In addition to the standard criteria, specific exclusion criteria were liver cirrhosis and the inability to provide standard conditions for the bleeding prevention (high central venous pressure, fragile liver parenchyma due to severe steatosis and other advanced drug-induced changes). Primary endpoint was ratio of blood loss to resection area (mL/cm2).
Results: Totally 68 patients were enrolled with 32 and 36 patients included in WJD and CUSA groups, respectively. Tumor size was significantly large in WJD group without differences in other local parameters (table). No differences were found in immediate outcomes including blood loss, blood/resection area ratio, morbidity and others (table).
Conclusions: Specialized liver parenchyma transsection devices (CUSA and WJD) have similar efficacy and safety in laparoscopic liver resection. The choice of instrument may be determined by the surgeon's preference.
ParametersWater Jet destructor n-32CUSA n-36P
Tumor size (mm)71 (18-211)51 (16-165)0,049
Difficulty score (points)7 (2-12)7 (2-12)0, 386
Malignant/benign lesions, n13/1423/180,502
Blood loss (mL)195 (10-400)218 (10-1400)0,604
Blood loss/resection area (mL/cm²)3,9 (0,9-10,6)5,0 (0,4-20,0)0,385
Pringle maneuver (n, %)15 (47%)21 (58%)0,862
Liver parenchyma transsection time (min)107 (19-305)100 (20-300)0,882
Severe morbidity (>II g, CD, n, %)2 (6%)2 (6%)0,903
Hospital stay (day)8 (5-16)8 (4-19)0,233
[Perioperative data in groups]
PG04-05 Non Surgical Procedure Related Postoperative Complications Independently Predicts Peri Operative Mortality, in Gastrointestinal and HPB Surgeries: A Retrospective Analysis
Bhavin Vasavada, India

B. Vasavada, H. Patel
Hepatobiliary and Liver Transplantation, Shalby Hospitals, India

Aim: The Aim of the study was to evaluate relationship between non surgical procedure related complication and 30 days mortality.
Material and methods: All gastrointestinal and hepatobiliary procedures performed in last 2 years have been evaluated retrospectively.Non surgical procedure related post operative complications were defined as peri operative complications non related to surgical procedures or techniques and related to patients' physiological health or comorbidities (e.g acute kidney injury, ARDS, acute respiratory failure, pre existing sepsis etc.), Surgical related complications were defines as peri operative complications related to surgical procedures or techniques (e.g. bleeding, leaks, sepsis due to leaks etc.). Factors affecting 30 days mortality and morbidity were analysed using univariate and multivariate analysis.Statistical analysis was done using SPSS (IBM).
Results: Total 315 major hepatobiliary and pancreatic surgery were done in our institute in last 2 years. 30 days overall mortality rate was 6.3 percents. In univariate analysis mortality was significantly associated with non surgical procedure related complications was significantly associated with 30 days mortality. (p < 0.0001). Surgical related complications was not associated with mortality. On univariate analysis other factors associated with mortality were open surgeries, emergency surgeries, advances age, high grade of surgery, higher ASA grades, increase operative duration, increased blood product requirements. However on multivariate analysis only non surgical procedure related postoperative complications independently predicted mortality.
(p=0.046, odds ratio 6.139).
Conclusions: Non surgical procedure related post operative complications (patient related) is strongly associated with 30 days mortality, suggesting improved perioperative care can help to reduce post operative mortality.
PG04-07 Long-term Dependency Outcomes in Older Adults Following Hepatectomy and Pancreatectomy for Cancer: A Population-based Analysis
Sean Bennett, Canada

S. Bennett1, T. Chesney1, N. Coburn1, B. Haas1, V. Zuk2, A. Mahar3, A. Hsu4, H. Zhao2, J. Hallet1, Recovery after Surgical Therapy for Older Adults Research - Cancer (RESTORE-CANCER)
1Surgery, University of Toronto, Canada, 2University of Toronto, Canada, 3University of Manitoba, Canada, 4University of Ottawa, Canada

Introduction: Older adults (OA) (>70 years old) comprise over half of incident cancers. We evaluated homecare use and institution-free survival (IFS) following hepatectomy and pancreatectomy in OA.
Methods: Patients >= 70 undergoing hepatectomy or pancreatectomy (2007-2017) were analyzed using administrative datasets. Outcomes were receipt of homecare and IFS, defined as < 14 days in healthcare institutions within one year. Time-to-event analyses accounted for competing risk of death.
Results: 982 patients underwent hepatectomy and 1283 pancreatectomy. Homecare use was highest in month-1 (72.3%) and decreased between year-1 (25.5%) and year-5 (18.3%). Female sex (HR 1.18) and adjuvant therapy (HR 1.56) were associated with increased hazards of receiving homecare. Ratio of nursing care vs. personal support services reversed from 68%/26% in year-1, to 29/64% in year-5. IFS dropped most in year 1 (40.6%), then gradually to year 5 (28.1%). Ratio of acute care vs. nursing homes went from 77%/14% in year-1 to 23%/70% in year-5. Duodenal (HR 1.45) and pancreas (HR 1.20) cancer and rural residence (HR 1.24) were independently associated with inferior IFS, and systemic/radiation therapy (HR 0.88) with superior IFS. Increasing age was neither associated with homecare receipt nor IFS.
Conclusion: Following HPB cancer surgery, there is a high rate of healthcare dependency for OA. There is immediate need for homecare that reaches a new baseline after 6 months. Most will spend 2 weeks in one year in institution, the majority in the first year. This outlines the need for pre-operative transitional care planning, tailored by risk factors identified herein.
PG04-08 Pancreatic Computed Tomography Standardised Reporting Templates: Can We Improve Report Quality in Pancreatic and Peri-ampullary Malignant Tumours?
Rashid Ibrahim, United Kingdom

R. Ibrahim1, R. Hodnett2, G. Miles2, M. Puckett2, S. Aroori1
1Hepato-Pancreatico-Biliary Surgery, University Hospitals Plymouth NHS Trust, United Kingdom, 2Radiology, University Hospitals Plymouth NHS Trust, United Kingdom

Accurate pancreatic/periampullary cancer staging and resectability assessment is vital to optimise patient care and where appropriate, surgical management and outcomes. Our tertiary hepato-pancreatico-biliary surgical centre receives referrals from several local hospitals. Imaging is performed and reported locally prior to referral, with subsequent heterogeneity of practice in protocolling and reporting prior to specialist GI radiologist review for multi-disciplinary team meeting (MDTM). Use of reporting templates has the potential to reduce heterogeneity and improve report quality and, ultimately, patient outcomes.
We searched our surgical database to identify all consecutive surgically-managed patients with confirmed diagnosis of pancreatic/periampullary malignancy over 18 months. CT imaging contemporaneous to decision to operate was anonymised and audited against a modified National Comprehensive Cancer Network® (NCCN) reporting template. The same imaging was reviewed by two experienced GI radiologists using the same template, new reports were compared to the originals. Statistical significance was assessed with Student t-test; k-values for interobserver relatability were calculated.
59 consecutive patients (37 male, 22 female), mean age 66 (36-83), were managed surgically during this period. Histology confirmed 49 adenocarcinoma (ductal 25, periampullary 8, unspecified 19), 7 NET or mixed adenocarcinoma/NET.
Original reports (n=59) contained mean key features ± standard deviation of 5.05±1.94 (range, 1-9). Template reports (incomplete data, n=13) contained 13.69±0.63 features (range, 12-14), P< 0.005). K-values and full results to follow.
Utilising reporting template resulted in more complete and accurate disease evaluation and is likely to have improved interobserver relatability; therefore it is likely to lead to better surgical planning and improve patient outcomes.
PG04-10 Incidence of Deep Vein Thrombosis in Hepato-Biliary Pancreatic Patients
Ryuta Nishitai, Japan

R. Nishitai, N. Sasaki, H. Ann, T. Ohta, R. Kudo, K. Kawaguchi, S. Konishi, S. Hamasu, D. Manaka
Department of Surgery, Kyoto Katsura Hospital, Japan

Aim and methods: More than 20% of Japanese patients was reported to have asymptomatic postoperative deep vein thrombosis (DVT). Considering the aggressiveness of surgery, hepato-biliary pancreatic (HBP) patients may have higher incidence of DVT. To evaluate the risk, a consecutive 196 patients were examined by doppler ultrasonography before and after major HBP surgery since November 2015 until July 2019. All the patients received intermittent pneumatic compression of the lower thigh but did not receive prophylactic anticoagulant. D-dimer (µg/ml) was also tested.
Results: Preoperative screening identified venous thrombi in the soleus or popliteal vein of 24 patients. DVT deteriorated in 5 of the 24 patients, and 4 new patients appeared out of the 172 DVT negative patients after the operation. The risk factors of preoperative DVT were age, female and elevated D-dimer. Those of postoperative development of DVT was pre-existing DVT and preoperative D-dimer elevation. The aggressiveness of surgery, such as types of surgery, operative time, or blood loss, did not relate to the incidence of postoperative DVT. Postoperative D-dimer value ranged widely and was not useful in estimating risk of postoperative VDT. Elevated preoperative D-dimer level > 1.2 µg/ml was supposed to be a good marker of postoperative deterioration of DVT whose sensitivity and specificity were 89% and 73% respectively.
Conclusion: The incidence of DVT in HBP patients did not exceed general population. High risk patients would be distinguished by preoperative D-dimer values.
PG04-11 Optimising the Outcomes of Index Admission Laparoscopic Cholecystectomy and Bile Duct Exploration for Benign Biliary Emergencies: A Service Model
Zubir Ahmed, United Kingdom

Z. Ahmed1, J. Ng2, S. Jabbar2, A. Nassar2
1Transplantation, Guy's and St Thomas NHS Foundation Trust, United Kingdom, 2Monklands Hospital, United Kingdom

Introduction: Despite overwhelming evidence of its clear benefit, the rate of early / index admission laparoscopic cholecystectomy (LC) +/- bile duct exploration (LDBE) for acute calcular biliary presentations remains low. We describe a service model designed for such patients.
Methods: Patients were identified from a prospectively maintained database containing 5555 consecutive cases. Referral to the dedicated biliary firm was made according to a predefined protocol which included ultrasound scanning, avoidance of MRCP/ERCP and routine intraoperative cholangiography. A bespoke surgical job plan with operational contingency to carry out up to 60% of the workload as unscheduled biliary care was also devised.
Results: 2399 (43.2%) emergency cases were undertaken. The median age was 52 years with 70% female. Patients were admitted with biliary colic (34%), obstructive jaundice (26%) and acute cholecystitis (16%). 63% were referred by another surgical team, 8% from external hospitals and 6% from internal physicians. 19% operated on the day of referral, 39% within 48 hours. 80% within 5 days. 44% were performed on an "elective list ", 29% on semi-elective “CEPOD” lists and 26% while on-call. The median operating time was 75 minutes, median total hospital stay 7 days. The conversion rate was 0.7%, clavien 2+ complication rate 4.8% and mortality rate 0.1%.
Conclusion: Early index single stage admission intervention for calcular biliary emegencies is achievable for the majority of patients and within the constraints of current healthcare delivery systems. This current model suggests a potential blueprint for achieving more widespread quality improvement in this area.
PG04-12 Role of Immunization Prior to Planned Splenectomy with Distal Pancreatectomy
Cheryl Ernst, United States

C. Ernst
Hepatobiliary Pancreatic Surgery, St Peter's Hospital, Albany, United States

The Advisory Committee on Immunization Practices of the Center for Disease Control and Prevention (CDC) under the United States Department of Health and Human Services release yearly recommendations on adult immunization schedules. This includes recommended adult immunization schedules based on medical condition. There is clear documentation that patients with asplenia (or compliment deficiencies) receive multiple immunizations. Asplenia increases a patient's risk for fulminant bacteremia and septicemia caused by encapsulated bacteria and increases their mortality. Anatomic or functional asplenia is frequent in cancer patients. Patients who undergo splenectomy for a hematologic or structural malignancy have a higher risk of hospitalization or death from sepsis than patients who are asplenic due to trauma. It is recommended that patients be vaccinated at least 2 weeks prior to scheduled splenectomy and subsequent chemotherapy. The immune system of patients with hyposplenia only mount a small antibody response to polysaccharide antigens and can result in vaccine failure if given after splenectomy. The same ineffectiveness of vaccines may occur during active chemotherapy or immunosuppression making it strongly advisable to vaccinate well before splenectomy due to malignancy potentially requiring neoadjuvant chemotherapy. It is the obligation of the treating physician or advanced practice provider to have knowledge of clinical guidelines of vaccines and offer patients the potential life-saving intervention when available. There is also a professional, ethical, and legal obligation for licensed providers to educate patients of risks and benefits involving immunizations and obtain informed consent to any treatment that is invasive or poses a risk to the patient.
PG04-13 Porto Systemic Shunt Surgery - Case Series of 40 Cases Performed at a Single Tertiary Care Centre
Rajesh Yadav, India

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

Introduction: Portal hypertension is seen when there is pathological increase in hepatic venous pressure gradient. Portal hypertension is seen in a number of conditions like extra-hepatic portal venous obstruction, cirrhosis of liver, non cirrhotic portal fibrosis, portal vein thrombosis from various causes. Surgical Porto systemic shunts are a time proven modality for treating portal hypertension. These patients present as recurrent variceal bleeding, ascites, encephalopathy. This is a case series on Porto systemic shunting done in patients in a single tertiary care centre.
Method: Retrospective study of 40 cases performed in a single tertiary care centre performed over 5 years from 2012 to 2016, along with comparison with the existing data on Porto systemic shunt surgeries.
Results: From amongst the 40 patients cases of extra-hepatic portal venous obstruction were 75%, non cirrhotic portal fibrosis were 15%, portal vein thrombosis were 5%, cirrhotic patients were 5%. There was no immediate peri-operative mortality. 4 year shunt patency was 97%. Recurrent variceal bleeding was seen in 5%. Encephalopathy was seen in 1%. Re-intervention was required in 3%. 4 year survival was 96%.
Conclusions: Surgical Porto systemic shunts remain time tested efficacious modality in management of portal hypertension. Porto systemic shunts have good long term survival benefit with symptomatic relief and improvement of quality of life.