absence of robust data, P4S was conducted to evaluate outcomes ... Aims: Enhanced recovery pathways (ERP) have been ... resection in a high volume centre.
E-HPBA: Poster Abstracts previous PVO (portal vein embolization, portal vein ligation or both) resulted in insufficient effect on FLR (n = 6), or where tumour localization made PVO unsuitable (n = 4) were prospectively included. Salvage ALPPS (only parenchymal transection) was performed in patients with previous PVO and standard ALPPS in patients without previous PVO. All patients were studied with CT x 2, hepatobiliary scintigraphy with SPECT/CT x 4, ICG x 6 and liver lab tests x 6. Volumetric analysis was performed at 4 occasions. Results: FLR growth was 60.1 % (range 32.3e116.2) 6 days after stage 1. FLR grew an additional 19.8 % (range 2e57.2) 7 days after stage 2 and 11.4 % (range 1.7e87.9) 30 days after stage 2. The increase of the FLR-F (Future Liver Remnant - Function) was 132 % (range 15e182.7) 6 days after stage 1. FLR/TL-F (FLR/Total Liver - Function %) was 24.1 (range 17.2e38.5) before stage 1 and increased to 58.5 (range 36.9e87) 6 days after stage 1. ICG-R15 was 9.9 % before and after stage 1, until after stage 2 where it rose to 33.3 % and remained at a high level (22.2 % in median) even 30 days after stage 2. No patient fulfilled the Balzan criteria for severe posthepatectomy liver failure. Bilirubin levels five days after stage 2 was 20 (12e49) and INR was 1.5 (1.2e1.8). Conclusions: Following ALPPS the FLR function increases more than twice as much as the increase in volume. The high levels of ICG-R15 after stage 2 in ALPPS are not associated with significant liver failure.
LIVER 0397 THE POST-SIR-SPHERES SURGERY STUDY (P4S): INFLUENCE OF PRIOR CHEMOTHERAPY ON SURVIVAL FOLLOWING HEPATIC RESECTION IN PATIENTS WITH METASTATIC COLORECTAL CANCER PREVIOUSLY TREATED WITH SELECTIVE INTERNAL RADIATION THERAPY (SIRT) M. R. Schön1, F. Pardo2 and B. Sangro2 1 Klinikum Karlsruhe, Germany; 2Clinica Universidad de Navarra, Spain Aims: SIRT (or radioembolisation) has been used in metastatic colorectal cancer (mCRC) to down-size liver tumours for subsequent surgical resection. To overcome the absence of robust data, P4S was conducted to evaluate outcomes of liver resection following SIRT. Methods: P4S was an international, multicentre, retrospective study to assess outcomes associated with liver resection or transplantation following SIRT using yttrium90 resin microspheres (SIR-Spheres; Sirtex Medical, Sydney). Primary endpoints were peri-operative and 90day post-operative morbidity and mortality. Results: Data were collected from 100 patients; 30 patients had mCRC (mean [sd] age, 61.0 [11.3] years; ASA score 3 in 53.6%; median follow-up post-SIRT, 32.3 months). Median (IQR) time from last SIRT to surgery was 3.6 (4.0) months. 10 (33.3%), 12 (40.0%) and 8 (26.7%) patients received no-lines, 1-line or >1-line of
HPB 2016, 18 (S2), e685ee738
e701
pre-SIRT chemotherapy, respectively; 11 (37%) received post-SIRT chemotherapy. Resection was major (3 segments) in 24 (80%) patients, and extended (5 segments) in 12 (40%) patients; 7 patients received ALPPS. Patients with >1-line of pre-SIRT chemotherapy were more likely to undergo extended resection (75% vs. 40% and 17% in patients receiving no-lines and 1-line, respectively). Complete resection (R0) was achieved in 24 (80.0%) patients, R1 in 5 (16.7%) and R2 in 1 (3.3%). Post-operative (any Clavien-Dindo-grade) complications were observed in 20 (66.7%) patients (grade 3+ in 16 [53.3%]), and post-operative liver failure in 7 (23.3%) patients (grade 3+ in 5 [16.7%]). Cumulative 30-day and 90-day all-cause mortality from first hepatic surgery was 1 (3.3%) and 3 (10.0%), respectively. No deaths appeared directly related to prior SIRT. Median (95% CI) survival was 29.3 (0.9e71.0) months, 39.4 (19.3e69.4) months and 11.5 (1.6-nr) months post-surgery in patients receiving no-lines, 1-line or >1-line of pre-SIRT chemotherapy, respectively. Conclusions: Complications in resected mCRC patients following SIRT appear similar to published studies. Overall survival was encouraging in patients with 1-line of preSIRT chemotherapy.
LIVER 0400 IMPLEMENTATION OF AN ENHANCED RECOVERY PATHWAY AFTER LIVER RESECTION: SINGLE CENTRE UK EXPERIENCE B. Dasari, R. Rahman, J. Isaac, R. Marudanayagam, D. F. Mirza, P. Muiesan, K. Roberts and R. P. Sutcliffe University Hospital Birmingham NHS Foundation Trust, UK Aims: Enhanced recovery pathways (ERP) have been adopted for a range of procedures, and lead to faster recovery, earlier discharge and reduced morbidity. The evidence in support of a role for ERP after liver resection is limited. The aim of this study was to evaluate the feasibility and outcomes of an enhanced recovery pathway after liver resection in a high volume centre. Methods: Since January 2014, all patients referred to our unit for liver resection have been managed within an ERP, excluding patients (N = 27) undergoing complex procedures (live liver donation, ALPPS or simultaneous colonic, bile duct or vascular resection). Short-term outcomes were compared between patients treated during two consecutive six-month periods (JulyDecember 2013 and January-June 2014), before and after introduction of ERP. Factors affecting length of hospital stay (LOS) were evaluated by multivariate analysis. Results: Patient demographics and resection type were similar pre-ERP (N = 93) and post-ERP (N = 91). 11/22 (50%) ERASÒ interventions were already in routine practice in our unit before ERP, compared to 20/22 (91%) after ERP. Severe (Clavien grade III-V) complications were less common post-ERP (14% vs. 4%, p = 0.04) but there was no difference in hospital mortality (1% vs. 1%; p = 0.7), median time to discharge criteria (5 vs. 5 days;
e702
E-AHPBA: Poster Abstracts
p = 0.9), median hospital stay (6 vs. 6 days; p = 0.9) or 30day readmission rate (13% vs. 10%, p = 0.6). Hospital stay was five days or shorter in 44% of pre-ERP patients and 46% of post-ERP patients. Patient age (p < 0.001), open surgery (p < 0.001) and postoperative complications (p < 0.001) were associated with longer hospital stay on multivariate analysis. Conclusions: An enhanced recovery pathway is feasible and may reduce complications after liver resection. Median length of hospital stay, which was already short in pre-ERP patients, was influenced by age, open surgery and postoperative complications, but was not reduced by introducing the pathway.
LIVER 0401 CRITICAL ASPECTS IN THE MANAGEMENT OF HCC: INDICATIONS TO HEPATIC RESECTION ACCORDING TO BCLC SYSTEM F. Romano, S. Nespoli, M. Garancini, F. Uggeri, L. Nespoli, L. Degrate, M. Sandini and L. Gianotti San Gerardo Hospita, Italy Aims: BCLC is considered the most reliable staging systems for HCC. Current criteria for hepatic resection seem to be limited and possibly arbitrary,not considering miniinvasive approaches and excluding some patients from a curative treatment. The aim of the study was to analyze the short- and long-term outcomes of HCC treated with hepatic resection, comparing them according to the BCLC stage and on a temporal basis. Methods: Patients who underwent hepatic resection for HCC over a 10-years period, (January 2004 e June 2014, were selected: the 72 resulting patients were grouped according to the BCLC, showing 10 BCLC 0 (13%), 38 BCLC A (53%), 24 BCLC B (31%) and 2 BCLC C (3%). Analysis of post-operative mortality and morbility, overall survival and disease-free survival and multivariate analysis of prognostic factors were performed. Results: The 30- and the 90-day mortality rates were 1.5% and 4.4%. Overall morbidity was 46% with 10% of major complications, with a considerable difference between patients treated in 0-A and B-C stages. After a 21 months median follow-up (range 1e140) the 1-3-5-year overall survival rates were 87.5%, 46.7%, 18.2% for BCLC 0-A and 89.5%, 64.3%, 46.2 for BCLC B-C (P = 0.467) with 1-3-5-year disease-free survival rates of 66.7%, 26.7%, 18.2% for BCLC 0-A and 68.4%, 50%, 30.8% for BCLC B-C (P = 0.652). A greater difference was found comparing patients treated before and after 2012 (P = 0.206) The multivariate analysis identified the tumoral Edmondson grading to be a prognostic factor for overall survival. Conclusions: 57% of patients underwent hepatic resection despite BCLC contraindications, and some conditions are better to be considered as negative prognostic factors; the disease-free survival data show that a curative surgical treatment may be proposed to B and C stages patients. An
accurate selection via multisciplinary approach and the introduction of conservative surgical techniques improve mortality and morbidity post-operative rates.
LIVER 0410 ALPPS MONOSEGMENT RESECTIONS ALLOW A FURTHER EXTENSION OF THE LIMITATIONS OF RESECTABILITY IN COLORECTAL LIVER METASTASES E. Schadde1, M. Malago2, R. Hernandez-Alejandro3, J. Li4, E. Abdalla5, V. Ardiles6, G. Lurje2, S. Vyas2, M. Machado7 and E. De Santibanes6 1 University of Zurich, Switzerland; 2University College London; 3London Health Sciences Centre, UK; 4University Medical Center Hamburg-Eppendorf, Germany; 5 Lebanese American University, Lebanon; 6Italian Hospital Buenos Aires, Argentina; 7University of Sao Paolo, Sao Paolo, Brazil Aims: The most extensive liver resections according to the Brisbane classification are right or left trisectionectomies, leaving two Couinaud-segments behind. The novel ALPPS technique (Associating Liver Partition and Portal Vein ligation for Staged hepatectomy) induces rapid and extensive liver regeneration prior to resection and recently led to case reports about resections leaving only one segment behind. Aim of this study was to evaluate the International ALPPS registry to see how many monosegment resections have been performed and to systematically evaluate their technique and outcome. Methods: Recordns of the international ALPPS registry (NCT01924741) from 2011 to 2014 were screened for liver resections leaving only 1 Couinaud segment or one segment and segment 1 as a liver remnant. Anatomy of tumors and indications for ALPPS, surgical technique, complications, survival and recurrence were evaluated. Results: Among 333 Patients undergoing ALPPS, 12 underwent ALPPS monosegment resections. All patients had colorectal liver metastases (CLRM) and had received chemotherapy prior to resection with either response or stable disease. Size of lesions and involvement of vascular pedicles justified the resectional approach. In 2 patients the remnant consisted of segment 2, in 2 of segment 3 , in 6 of segments 4 and 2 of segment 6. Median time to proceed to stage 2 was 13 days and median hypertrophy of the liver remnant was 160%. There was no mortality. Four patients experienced liver failure, but all recovered. Complications >IIIA Dindo-Clavien occurred in 4 patients with no long term sequelae. At a median follow-up time of 14 months, 6 patients are tumor free and 6 patients developed recurrent metastatic disease. Conclusions: ALPPS allows the systematic use of single segments liver remnants in patients with colorectal liver metastases, a novelty in liver surgery. In conjunction with chemotherapy this technique will allow a further extension of the limitations on resectability of CLRM.
HPB 2016, 18 (S2), e685ee738
