P-BN53 The ‘Difficult Gallbladder’: do no harm!

Background Laparoscopic cholecystectomy (LC) for a ‘difficult gallbladder’ can incur increased risk of biliary complications. In these challenging conditions where anatomical delineation (commonly through the critical view of safety) is unachievable, it is important to recognise when to proceed and when to consider a bail-out strategy. Subtotal cholecystectomy (SC), cholecystostomy insertion, conversion to open or abandoning the procedure are accepted solutions. In this study we review the outcomes of patients who underwent LC following previous intervention. Methods We retrospectively reviewed patients who underwent LC under a single surgeon between January 2009 to July 2020 following a previous intervention with LC, SC or cholecystostomy tube insertion. Data was collected with regards to demographics, clinical presentation, intraoperative details, imaging, conversion to open, length of hospital stay and complications. Results 40 patients with previous intervention underwent LC. Previous intervention included abandoned LC in 24(60%), on-table cholecystostomy in 8 (20%) and SC in 8 (20%), with 5(13%) converted to open. Reasons for referral included adhesions, intrahepatic gallbladder, possible malignancy, empyema and abnormal anatomy. Laparoscopic approach attempted in 39/40 (98%), conversion to open in 25%. Reasons for conversion included cholecystoduodenal fistula, and suspected malignancy. Median hospital stay was 4 days (1 – 22). Morbidity was seen in 2(4%) with no biliary complications. Completion of treatment, from previous intervention to definitive LC was 9 months (1-48). Conclusions In patients with previously attempted cholecystectomy, LC is feasible and can be performed with low morbidity. When faced with a difficult gallbladder intra-operatively, aborting the procedure and re-attempting at a later date, locally or referral to a specialist Unit, should be considered.

Early biliary complications after pancreatoduodenectomy

This study aimed to review latest investigations concerning early biliary complications following major pancreatic surgery. 127 original articles in English language were found via PubMed literature search using key words over the last 5 years. After application of exclusion criteria (full-text in English not available, duplicating paper, age of paper over 5 years) a total of 29 articles were included in this study. Herein we review epidemiology and classification of early biliary complications after pancreatoduodenectomy, current views on pathogenesis, prophylaxis, diagnostics and treatment of early biliary complications. In early postoperative course of pancreatoduodenectomy patients may develop transient jaundice, cholangitis, early biliary strictures and post-procedural bile leak. Frequency of these conditions range from 3 to 24% and depends on epidemiological features of population, statistics and combined conditions. A number of patient- and surgery-dependent risk factors have been described. Modern interventional radiology offers a wide range of procedures for diagnostics and treatment of early biliary complications after pancreatoduodenectomy which showed to be safe and effective when endoscopic manipulations are contraindicated due to high risk. Well-timed diagnosis and treatment allow to avoid severe early biliary complications, re-interventions and reoperations which provides a good prognosis and lowers medical and financial burden.

The incidence and risk factors of chronic rejection in acutely rejected pediatric liver transplantation

Background. Chronic graft rejection (CR) represents an increasing concern in pediatric liver transplantation (LT). Risk factors of CR in this population are uncertain. In present study, we aimed to ascertain if clinical parameters could predict the occurrence of CR in LT children.Methods. We retrospectively analyzed the results from 47 children who had experienced acute hepatic rejection in Namazee hospital, Shiraz, Iran during 2007–2017.Results. Out of 47 children, 22 (46.8%) and 25 (53.2%) were boys and girls respectively. Ascites, gastrointestinal bleeding, and spontaneous bacterial peritonitis were observed in 20 (44.4%), 14 (31.1%), and 4 (9.1%) respectively. Posttransplant vascular and biliary complications were observed in 3 (7%) and 4 (9.3%) cases respectively. The mean time from LT to normalization of liver enzymes was 14.2 ± 7.5 days. The mean of acute rejection episodes was 1.4 ± 0.6 (median = 1 (22, 46.8%), range of 1–3). Six (12.7%) patients experienced CR. The mean time from LT to CR was 75 ± 28.4 days. A significant association was found between CR and patients’ condition (being inpatient or outpatient) before surgery (P = 0.03). No significant relationship was found between CR and post-transplant parameters except for biliary complications (P = 0.01). Both biliary complication (RR = 33.7, 95% CI: 2.2–511, P = 0.01) and inpatient status (RR = 10.9, 95% CI: 1.1–102.5, P = 0.03) significantly increased the risk of CR.Conclusion. Being hospitalized at the time of LT, and development of biliary complications might predict risk factors for development of CR in LT children.

Biliary-Caval Fistula following Y90 Radioembolization

The safety of radioembolization with yttrium-90 (90Y) is well documented and major complications are rare. Previous studies have demonstrated that biliary complications following 90Y, including bile duct injury and hepatic abscess formation, occur at an increased rate in patients who have had prior biliary surgery and interventions. This article reviews a case of a patient who developed recurrent cholangitis and sepsis as well as a biliary-caval fistula following radioembolization. Additionally, we review current data regarding biliary complications following radioembolization in patients with prior biliary intervention.

EP.TH.43Biliary cooling during radiofrequency ablation of liver tumours close to central biliary tree: A systematic review and pooled analysis

Aims Biliary cooling during radiofrequency ablation (RFA) of liver tumours has been proposed as a protective measure for RFA-related biliary complications in cases whereby the RFA-site is close to central biliary tree. This systematic review aims to assess the effect of biliary cooling on i) the development of biliary complications and ii) tumour recurrence rates at ablation site. Methods A systematic literature search was performed using the PubMed/EMBASE databases using PRISMA methodology (2000-2019). The initial search yielded 75 reports which were potentially suitable for inclusion. Studies reporting at least one outcome of interest were considered to be suitable for inclusion. Conference abstracts, case reports and animal studies were excluded. Data was retrieved on patient demographics, tumour characteristics, method of cooling, biliary complications, local tumour recurrence and duration of follow-up. Results The final number of studies which met the inclusion criteria was 7, involving 100 patients. There were no randomized controlled trials identified after the literature search. The mean age of the patients included was 65 years. Biliary cooling was performed with the use of a nasobiliary tube in 4 out of 7 studies, via a choledochal incision in 2 out of 7 studies and through the cystic duct in a single study. The overall biliary stricture rate was 2% and the overall tumour recurrence rate at RFA treated site was 14.5%. Conclusion Biliary complications appear to be low after biliary cooling during RFA close to central biliary tree. More evidence is required to assess the tumour recurrence rates.