O-BN06 A Proposed Difficulty Grading System for Laparoscopic Bile Duct Exploration. Benefits to Practice and Research

Background A gap remains between the mounting evidence for single session management of bile duct stones and the obstacles to wider adoption of this approach. The practice of laparoscopic bile duct exploration (LCBDE) is limited not only by the availability of training opportunities and adequate equipment but also by the perception that the technique is difficult and requires a high skill-set. The aim of this analysis is to compare the preoperative and operative characteristics and the postoperative outcomes in easy vs. difficult LCBDE in a large consecutive series, according to a proposed 5 grade classification. Methods 1326 LCBDEs were graded according to the location, number and size of ductal stones, retrieval techniques used, utilisation of choledochoscopy and specific biliary pathologies encountered. The cohort was divided into two groups: easy (Grades I A&B, and Grade II A&B, requiring transcystic or transductal exploration for up to 15 stones the largest being 15mm) and difficult (Grades III A&B, for over 15 stones or intrahepatic stones of any size needing transcystic choledochoscopy, IV and V with Mirizzi Syndrome, impacted stones, and ducts needing stenting, conversion or bilioenteric anastomosis). Various outcome parameters were compared. Results Age, sex, obesity and previous biliary admissions had no effect on operative difficulty. Emergency admission, obstructive jaundice, previous ERCP and dilated CBD were predictive of difficult explorations. 78.3% of patients with acute cholecystitis or pancreatitis, 37 % of jaundice and 46% of cholangitis had easy explorations. Transcystic stone retrieval was possible in 77.7% of easy explorations and choledochotomy required in 62.3% of difficult explorations (vs. 33.6% in the whole series). Choledochoscopy was utilised in 23.4% of Grades I&II vs. 98% in difficult explorations. As expected more biliary drains, stenting, bilio-enteric anastomosis, conversions, operative time, biliary-related complications, hospital stay, readmissions and retained stones increased with difficulty. Grades I&II patients had 2 or more hospital episodes in 26.5% vs. 41.2% for grades III to V, the median presentation to resolution interval increasing from 1 to 3 weeks. There were 2 deaths in difficulty Grade V and one in Grade IIB. Conclusions Difficulty grading of LCBDE is a useful tool of predicting outcomes. It facilitates comparison between studies and fair assessment of training. LCBDEs are easy in 72% and of these 77% can be completed transcystically. It is hoped this will encourage more units to adopt single session management of bile duct stones through establishing referral protocols, developing and refining the skills through training and acquiring the necessary equipment.

743 Inflammatory Pseudotumor (IPT) Of the Liver, A Diagnostic Dilemma with Therapeutic Uncertainty in A cohort of Bangladeshi patients (Observational Cohort Study)

Background IPT a benign lesion seldom encountered in clinical practice. It’s mysterious in origin & remains ambiguous.Infection, stone,autoimmune disease,systemic inflammatory response,trauma,foreign body and neoplasm attributes to etiological factors.Advanced imaging modalities help in increased detection of focal liver lesion. Aim To analyze its clinical significance. 33 patients with focal liver lesions were evaluated and treated surgically as hepatic neoplasm consecutively from July 2013 to January 2020. Method Retrospective observational cohort study. Results 14 male & 19 female were studied, mostly in 3rd decade of life. Clinically only 21% of them presented with fever.In 24 patients the lesions were located in left lobe of liver.The operative procedures were: wedge resection in 3 patients,limited resection in 5 patients,Left Hepatectomy 7 patients,Left lateral hepatic segmentectomy in 17 patients, right hepatectomy in 2 patients & central hepatectomy in 1 patient. 8patients required bilioenteric anastomosis as additional procedure.Histopathological study revealed Tuberculosis in 7 patients(21.21%),fungal granuloma in 3 patients, foreign body granuloma in 3 patients, Ductal calculi with abscess in 9 patients and idiopathic in 7 patients. Conclusions IPT of liver represents a rare entity usually mistaken as malignant lesion.Despite the low prevalence, it often creates a diagnostic dilemma resulting into therapeutic uncertainty.

Replaced Right Hepatic Artery Originating from the Common Hepatic Artery: A Case Report

The presence of an aberrant right hepatic artery is the most frequently encountered vascular anomaly during pancreaticoduodenectomy, and its recognition and preservation are of paramount importance to prevent ischemia of the bile duct and consequently the bilioenteric anastomosis, which can lead to anastomotic leak or dehiscence and fistula. In this case report, we describe proximal branching of the common hepatic artery (CHA) to give rise to a replaced right hepatic artery (RHA), which courses posterior to the portal vein (PV) and common bile duct (CBD) to the right lobe of the liver. The location of this replaced RHA in the hepatoduodenal ligament is consistent with the location of a replaced RHA described by the Michels classification, although with the important distinction that origin was the CHA instead of the superior mesenteric artery (SMA). From our review of the current literature, this is the first published description of such an anatomic course of the RHA.

Transjejunal Laparoscopic Assisted ERCP in a Patient with Roux-en-Y Hepaticojejunostomy

Background and Objectives: Nowadays, with the increasing laparoscopic expertise and accessibility to modern surgical tools, laparoscopic assisted ERCP (LAERCP) has become an effective approach for the management of bile stone disease in patients with modified gastrointestinal anatomy. In contrast to patients with gastric bypass in whom a transgastric LAERCP approach is usually performed, the resultant anatomy of Roux-en-Y hepaticojejunostomy precludes a gastric approach as the newly formed bilioenteric anastomosis is not reachable through the stomach. Therefore, a transjejunal approach has been described as an alternative LAERCP technique. To the best of our knowledge this is the tenth case of transjejunal LAERCP reported worldwide. Materials and Methods: We present the case of a 50-year-old female with history of biliary injury during a cholecystectomy corrected with Roux-en-Y hepaticojejunostomy who presented to our center with manifestations of acute abdomen. After laboratory and image analysis, diagnosis of intrahepatic lithiasis was confirmed. The decision to perform a transjejunal LAERCP was made due to the complex anatomy in this patient. No complications were found during surgery and in the follow up period. Conclusions: Transjejunal LAERCP is an effective approach for endoscopic management of biliary complications in patients with Roux-en-Y hepaticojejunostomy and other modified gastrointestinal anatomy. Previous recommendations by more experienced teams have been reported, nonetheless, there are too few cases reported to make definitive recommendations and conclusions. In limited settings, such as ours, some of these recommendations may not be applicable. We are certain that, with the increasing expertise and innovations in laparoscopy surgery for the management of complications that cannot be addressed by endoscopic or noninvasive measures, more cases will be reported.

Septic Shock and Death after Microwave Ablation of Hepatocellular Carcinoma in a Liver Transplant Patient with a Bilioenteric Anastomosis

Percutaneous thermal ablation of hepatic tumors continues to play an integral role in the treatment of early-stage primary or secondary hepatic malignancies. Interventional radiologists must be familiar with potential complications of this procedure, associated risk factors, and methods for prevention. The authors report a devastating case of septic shock and death following percutaneous microwave ablation of a solitary hepatocellular carcinoma in a liver transplant patient with a bilioenteric anastomosis (BEA). We review the literature regarding prophylactic antibiotic regimens and bowel preparation prior to performing thermal ablation in patients with BEAs.