, 2008
ANZ J. Surg. 2008; 78 (Suppl. 1) A68–A80
HPB & Upper GI Surgery
HP01
SURGICAL RESECTION FOR HEPATOCELLULAR CARCINOMA
W. Y. Lau
The Chinese University of Hong Kong, Shatin, Hong Kong
Surgical resection is still the most accepted form of “curative” treatment for
hepatocellular carcinoma (HCC).
Advances in diagnostic technology have improved on the diagnosis and
staging of HCC, allowed the optimum selection of patients and accurate
assessment of the required extent of liver resection, and the prediction of the
function of the remnant liver after resection. Improvements in pre-, intra- and
post-operative management have reduced the mortality rate for non-cirrhotic
liver resection to close to 0% and cirrhotic liver resection to below 5%.
Portal vein embolization and tumour downstaging allow patients who could
not be cured in the past because of small liver remnants or because of
advanced HCC to be cured with liver resection.
The appreciation of functional liver segments leads to the use of anatomical
resection. As a consequence, there is an effective clearance of all tumours with
the minimum amount of hepatic impairment.
The advances result in improved access through appropriate incisions and
retractors, better haemorrhage control, improvements in liver parenchymal
transection techniques, inflow ± outflow occlusion techniques, and anterior
approach/Glissonian sheath approach to liver resection.
The reported 5- and 10-year overall survivals are around 45% and 20%,
respectively. The cancer-free survival at 5 years is around 20%. There has
been increasing evidence to support the use of adjuvant therapy after liver
resection for HCC.
Conclusion: Live resection is still the main-stay of curative treatment for
HCC. Recent advances in knowledge and technology have made this treatment
safe and effective.
HP02
WHY SHOULD D2 GASTRECTOMY BE THE NORM?
T. Sano
National Cancer Center Hospital, Tokyo, Japan
Surgery plays a key role in gastric cancer treatment, and no cure can be
expected without surgery. D2 lymphadenectomy provides the best chance of
removing all metastases in the regional lymph nodes. Dutch D1/D2 trial failed
to show the benefit of D2 mainly due to high operative morbidity and mortality
in the D2 group. A new study using autopsy results of this trial (Hundahl SA.
Gastric Cancer 2007;10:84–6) revealed that patients with low possibility of
residual nodal disease had significantly better survival and fewer local recur-
rences than those with high possibility of residual nodal disease. In the
American Intergroup study 0116, chemoradiotherapy brought significantly
prolonged survival after limited (D0/D1) lymphadenectomy. All these suggest
that good local control is essential for cure of gastric cancer.
We should carefully select patients who would benefit from D2. For T1
gastric cancer, D2 is too much because lymph node metastasis is rare and is
almost limited to perigastric area. In very advanced disease, D2 will not affect
survival or may be even harmful. Patients with preoperative diagnosis of T2/
T3 and N0-N2 are good candidates for D2. Absence of peritoneal metastasis
should be confirmed before starting D2. Surgeons experience and hospital
volume are important factors for good results. Patient fitness is also important.
Even by experienced surgeons, morbidity is high in obese male patients.
Conclusion: D2 gastrectomy will provide the best local tumour control for
non-early gastric cancer when performed by experienced surgeons. Preoper-
ative accurate evaluation of the tumour is essential for selection of patients
who would benefit from D2.
Journal compilation © 2008 The Royal Australian and New Zealand College of Surgeons
HP03
BINDING PANCREATOJEJUNOSTOMY
S. Y. Peng, D. F. Hong, Y. P. Mou, X. J. Cai, B. Xu and J. T. Li
Dept of Surgery, Zhejiang University, Hangzhou, China
Objective: To introduce a new method called Binding Pancreatojejunos-
tomy (BPJ) for minimizing pancreatojejunostomy leakage after pancreati-
coduodenectomy (PD).
Method: BPJ is performed as follows: Firstly, the cut end of the pancreatic
remnant is isolated for a distance of 3 cm. 2, three cm of the jejunum cut end
is everted so as to expose the mucosa, which is then destroyed either by electric
coagulation. 3, the pancreatic stump and the everted jejunum are brought
together and sutured with 4 0 prolene, intermittently or continuously. Care is
taken to suture the mucosa only, and avoid penetrating the serosa and muscular
layer of the jejunum. 4 the everted jejunum is then turned down to it’s normal
position to wrap over the pancreatic stump and is sutured to the pancreas for
fixation. Lastly, 1 cm from the cut end of the jejunum, a catgut tie is looped
around the entire circumference of the jejunum overlying the pancreas. A
bundle of vessels is spared for maintaining blood supply to the jejunal cut end
distal to the binding ligature. An alternative way is using the binding ligature
only and the mucosa suture is omitted. The pancreatic duct may be inserted
with a short segment of catheter which is kept in the jejunum.
Results: This procedure is being used in more than hundred hospitals in
Mainland China for more than 3500 cases, the rate of pancreatojejunostomy
leakage is 0.5%.
Conclusion: binding pancreatojejunostomy is a simple, safe and efficient
technique which can significantly minimize the rate of pancreato jejunostomy
leakage.
HP04
LAPAROSCOPIC PARA-OESOPHAGEAL HERNIA REPAIR –
QUALITY OF LIFE OUTCOMES IN THE ELDERLY
E. J. Hazebroek, S. Gananadha, Y. Koak, H. Berry, S. Leibman and
G. S. Smith
Royal North Shore Hospital, Sydney, New South Wales
Background: Para-oesophageal hernias (POH) occur when there is herni-
ation of the stomach through a dilated hiatal aperture. These hernias occur
more commonly in the elderly who are often not offered surgery despite
the failure of medical treatment to address mechanical symptoms and life-
threatening complications. The aim of this study was to assess the impact of
laparoscopic repair of POH on quality of life in an elderly population.
Methods: Data were collected prospectively on 35 consecutive patients
>70 years undergoing laparoscopic repair of a symptomatic POH between
December 2001 and September 2005. The change in quality of life was
assessed using a validated questionnaire (QOLRAD) and by patient inter-
views. Patients were assessed pre-operatively, and at 6 weeks, 6 months, 12
months, 1 year and 2 years post-operatively.
Results: Mean patient age was 77 years (range: 70–85). There were 28
females and 7 males. There was one re-admission for acute re-herniation,
which required open revision. Total complication rate was 17.1%. All com-
plications were treated without residual disability. There was no 30-day
mortality and median hospital stay was 3 days (range: 2–14). Completed
questionnaires were obtained in 30 of 35 patients (85.7%). There was a
significant improvement in quality of life as measured with QOLRAD at all
post-operative time-points.
Conclusion: Laparoscopic POH repair can be performed with acceptable
morbidity in symptomatic patients refractory to conservative treatment and is
associated with a significant improvement in quality of life. Our data support
elective repair of symptomatic POH in the elderly, a population who may not
always be referred for a surgical opinion.
RACS Annual Scientific Congress, 2008
HP05
LAPAROSCOPIC REPAIR OF GIANT HIATUS HERNIA AND
RELATED ANEMIA – OUTCOME AND QUALITY OF
LIFE ANALYSIS
E. W. Wong and G. K. Krishna
Whangarei Hospital, Northland, New Zealand
Purpose: Giant hiatal hernias can be associated with iron deficiency ane-
mia and significant morbidity and mortality without repair. We report on the
outcomes of laparoscopic repair of giant hiatus hernias and correction of
associated iron deficiency anemia by a single surgeon in a provincial center
in NZ. We also report on the pre and post-op quality of life analysis.
Methodology: Prospective audit data were collected on all consecutive
patients who underwent laparoscopic repair of giant hiatus hernias between
2002–2007. All patients completed SF-36 Quality of life surveys before and
after the procedure. We compared anemic with non-anemic patients.
Results: 22 patients (10 anemic, 12 non-anemic) underwent surgery.
Median age was 63. In the anemic group, mean Hb was 96 g/l. There was 1
conversion due to laparoscopic equipment failure. Median hospital stay was
4 days. Mean followup was 39 months. 7 of 22 patients (32%) had compli-
cations. There was no mortality associated with procedure. 9 of 10 anemic
patients (90%) had correction of anemia post-op with mean Hb 142 g/l. 1 of
22 patient (4.5%) had a recurrence of hiatus hernia on barium swallow post-
op. Post-op SF-36 QOL survey demonstrated significant improvement in all
categories (p < 0.05). On subgroup analysis, non-anemic patients had signif-
icantly higher QOL scores compared to anemic patients (p < 0.05).
Conclusion: Laparoscopic repair of giant hiatus hernias is safe and effec-
tive in correcting associated iron deficiency anemia. Our results are compa-
rable to published series. This procedure improves quality of life for patients.
HP06
METABOLIC OUTCOMES AFTER LAPAROSCOPIC ADJUSTABLE
GASTRIC BANDING (LAGB)
H. Berry, E. J. Hazebroek, R. Hansen, R. Clifton bligh, B. Jones,
S. Leibman and G. S. Smith
Royal North Shore Hospital, Sydney, New South Wales
The aim of this study is to determine factors associated with hepatic steatosis,
inflammation and fibrosis in obese patients undergoing LAGB and to evaluate
the relationship between post-operative weight loss and markers of insulin
resistance, diabetes, liver disease and homocysteine.
Data were collected prospectively from 173 patients treated with LAGB.
Patients had paired liver biopsies and serial biochemistry. Univariate analysis
was performed to identify factors associated with hepatic steatohepatitis,
steatosis, fibrosis and insulin resistance (HOMA-IR). Outcome measures at
6 and 12 months included weight change, serum insulin, glucose, HbA1c and
cholesterol.
69% of patients were female; median age: 46 years; BMI: 45.9; weight:
132.7 kg. On liver biopsy, 4% had advanced liver fibrosis and 25% mild to
moderate fibrosis. The presence of moderate to severe steatosis (>47%) was
significantly associated with increasing BMI and elevated HbA1c, HDL, TG,
AST, ALT and GGT levels. Inflammation, steatosis, ballooning degeneration
and mallorys hyaline on liver biopsy were significantly associated with liver
fibrosis. Fibrosis was also significantly associated with increasing age and
elevations in AST and ALT. 12 months post-operatively, mean weight loss was
25.4 kg with statistically significant improvements in insulin, glucose, HBA1c
and liver function tests.
In an obese population undergoing LAGB, age and liver biopsy markers of
inflammation and hepatocyte injury were associated with liver fibrosis. Met-
abolic parameters were associated with the occurrence and severity of steato-
sis. Gastric banding results in sustained weight loss, improvements in LFTs
and metabolic parameters at 12 months.
Journal compilation © 2008 The Royal Australian and New Zealand College of Surgeons
A69
HP07
SURGICAL TREATMENT OF RESTRICTURE AFTER REPAIR OF
IATROGENIC BILE DUCT INJURY
S. Y. Peng, J. T. Li, Y. B. Liu, X. W. He, L. P. Cao and D. H. Hong
Dept of Surgery, Zhejiang University, Zhejiang, China
Purpose: Iatrogenic bile duct injury (IBI) remains a challenge to surgeons,
especially because the rate of restricture after repair (RAR) ranges from 10%
to 30% which is even higher in injuries at or above the biliary confluence.
The aim of this study is to explore optimal management of RAR. Method
Within a period of 8 years, 28 patients with RAR were referred to our center.
They had experienced 1–5 times of repair surgery before referral. Among them
12 cases were classified as grade III, 11 were grade IV. To achieve adequate
exposure of the proximal bile duct remnant, segment IV b were partially
resected in 4 cases and the Mid-plane was split in 8 cases.
Results: Excellent outcome were achieved in 21, good in 5 and fair in 2
patients during the follow-up from 1 to 10 years.
Conclusion: 1 The basic prerequisite for a successful repair of RAR is
fully exposure of the duct proximal to the stricture. 2 RAR at or above the
biliary confluence, identification and exposure of the proximal remnant would
be achieved by partial removal the overlying liver tissue. 3 In extremely
difficult cases, splitting the liver through Mid-plane is extremely helpful. In
some cases, the liver should be split to the point where the main trunk of the
middle hepatic vein and the right hepatic duct come across 4 When the gap
between the openings of right and left hepatic duct is too wide, it is advisable
to establish two separate anastomoses.
HP08
MANAGEMENT OF ASYMPTOMATIC GALLSTONES
V. Usatoff
The Alfred Hospital, Melbourne, Victoria
Early in the 20th century, William Mayo and Lord Moynihan proposed chole-
cystectomy in all patients with gallstones as there were no “innocent” gall-
stones. It wasn’t until the 1980’s that this teaching was significantly
challenged and it was suggested that asymptomatic gallstones be managed
with observation. This reasoning occurred during the era of open cholecys-
tectomy. The advent of laparoscopic surgery has lead to an increase in the
number of cholecystectomies being performed and a reconsideration of the
potential benefits of operating on incidental gallstones, at least in some
patients. This paper explores the arguments around this proposal, particularly
in the common case scenarios such as patients with large gall stones, diabetic
patients, transplant patients, those with a porcelain gallbladder, gallstones
noted during other abdominal surgery and those living in or travelling to
remote areas. The literature around these and other scenarios will be reviewed
and recommendations suggested based on available evidence.
HP09
TIMING OF SURGERY IN ACUTE ChOLECYSTITIS
M. A. Fink
Austin Hospital, Melbourne, Victoria
The optimal timing of laparoscopic cholecystectomy for acute cholecystitis
has been studied in five randomized controlled trials involving 418 patients,
213 randomized to early surgery (up to 3 days after admission) and 205
randomized to initial conservative management, followed by delayed elective
surgery (5 days to 12 weeks after admission) 1–6.
In the delayed surgery groups, conservative management failed, necessitat-
ing emergency cholecystectomy in 16% of patients and unplanned readmis-
sion prior to elective cholecystectomy occurred in a further 9%. Operation
time was significantly longer in the early than delayed groups in two studies
(median 135 vs 105 minutes, respectively, p = 0.0221, mean 123 vs 107
minutes, respectively, p = 0.042), there was a non-significant trend to longer
operation time in the early group in one study 6 and there was a non-significant
trend to shorter operation times in the early groups in the other two studies
3,4. The rate of conversion to open cholecystectomy was not significantly
different (23% in the early groups and 25% in the delayed groups). The
complication rate was 14% in the early groups and 13% in the late groups.
A70
Total hospital stay was significantly less in the early than delayed groups
in all studies (median 6 vs 11 days, respectively, p = 0.0011, mean 7.6 vs 11.6
days, respectively, p < 0.0012, mean 5.4 vs 7.1 days, respectively, p = 0.013,
median 5 vs 8 days, respectively, p < 0.055 and mean 4.1 vs 10.1 days,
respectively, p = 0.0236). Hospital charges were significantly less in the early
than delayed group in the one study in which it was investigated (mean
US$16,297 vs US$21,427, respectively, p = 0.01) 3. Return to work was
significantly faster in the early than delayed group in the one study in which
it was investigated (median 15 vs 26 days, respectively, p = 0.017) 1. Health
related quality of life was significantly better in the early group at one month
post surgery (p < 0.01), but no different at three and six months post surgery,
in the one study in which it was investigated 5.
Early laparoscopic cholecystectomy, in comparison to late laparoscopic
cholecystectomy, for acute cholecystitis results in reduced total hospital stay
without an increase in conversion to open operation or complications and is
associated with reduced costs, more rapid return to work and improved short
term quality of life.
References
1. Lo CM, Liu CL, Fan ST, Lai EC, Wong J. Prospective randomized study
of early versus delayed laparoscopic cholecystectomy for acute cholecys-
titis. Ann Surg 1998;227:461–7.
2. Lai PB, Kwong KH, Leung KL, Kwok SP, Chan AC, Chung SC, Lau WY.
Randomized trial of early versus delayed laparoscopic cholecystectomy
for acute cholecystitis. Br J Surg 1998;85:764–7.
3. Chandler CF, Lane JS, Ferguson P, Thompson JE, Ashley SW. Prospective
evaluation of early versus delayed laparoscopic cholecystectomy for treat-
ment of acute cholecystitis. Am Surg 2000;66:896–900.
4. Johansson M, Thune A, Blomqvist A, Nelvin L, Lundell L. Management
of acute cholecystitis in the laparoscopic era: results of a prospective,
randomized clinical trial. J Gastrointest Surg 2003;7:642–5.
5. Johansson M, Thune A, Blomqvist A, Nelvin L, Lundell L. Impact of
choice of therapeutic strategy for acute cholecystitis on patient’s health-
related quality of life. Results of a randomized, controlled clinical trial.
Dig Surg 2004;21:359–62.
6. Kolla SB, Aggarwal S, Kumar S, Chumber S, Parshad R, Seenu V. Early
vs delayed laparoscopic cholecystectomy for acute cholecystitis. Surg
Endosc 2004;18:1323–7.
HP10
DAMAGE CONTROL IN THE MANAGEMENT OF LIVER INJURY
D. R. W. Wall
Princess Alexandra Hospital, Brisbane, Queensland
Surgical intervention is required for severe liver injury (grade IV-VI) An
essential strategy is the application of techniques of damage control. In a
series of 400 injuries of the liver in the 21st century, intervention was required
in 43 patients. Damage control was required in 33. Two patients died from
head injuries and two from massive haemorrhage leading to a mortality of
12%. Secondary procedures included liver resection, bile duct reconstruction,
liver revascularization and radiological embolization. Ten techniques were
practiced in damage control. These techniques may be rehearsed and practiced
in vivo during RACS sponsored Definitive Surgery for Trauma Care (DSTC)
courses.
Reference
Strong R, Lynch S V, Wall D R. Anatomical resection surgery. 123:251.
HP11
MANAGEMENT OF COMPLEX PANCREATIC AND
DUODENAL INJURIES
J. S. Samra
Royal North Shore Hospital, Sydney, New South Wales
Complex pancreatic and duodenal injuries are relatively rare in Australasia.
Unlike, United States and South Africa, they are often caused by blunt trauma
rather than penetrating trauma. These patients are best managed in high
volume trauma centers in a patient orientated approach. It is important to
recognize these injuries early and manage them in the context of patient’s
clinical situation. In this presentation, we discuss the role of various investi-
Journal compilation © 2008 The Royal Australian and New Zealand College of Surgeons
ANZ J. Surg. 2008; 78 (Suppl. 1)
gation modalities in assessing the extent of pancreatic and duodenal injury.
The role of Organ Injury Scale (OIS) and pancreaticographic classification
of pancreatic duct injury is discussed in the management of these complex
injuries.
The introduction of new technologies such as magnetic resonance cholan-
giopancreaticography (MRCP) and endoscopic stents have had a significant
impact on the management of these patients. In addition, some surgical pro-
cedures such as pancreatoduodenectomy and distal pancreatectomy have
become more common in the armamentarium of trauma surgeons while others
have fallen out of favor. The aim of this presentation is to highlight the various
management strategies that can be useful in treating these complex injuries.
HP12
META-ANALYSIS OF LAPAROSCOPIC AND OPEN ANTI-REFLUX
SURGERY FOR GASTRO-OESOPHAGEAL REFLUX DISEASE
M. J. Peters, A. Muktar, R. M. Yunus, S. Khan, B. Memon and
M. A. Memon
Ipswich General Hospital, Ipswich, Queensland
Purpose: The aim was to conduct a meta-analysis of relevant randomized
clinical trials to determine the relative merits of laparoscopic anti-reflux
surgery (LARS) and open anti-reflux surgery (OARS) for proven gastro-
oesophageal reflux disease.
Methodology: A search of the Medline, Embase, Science Citation Index,
Current Contents and PubMed databases identified all randomized clinical
trials that compared LARS and OARS and were published in the English
language between 1990 and 2007. The meta-analysis was prepared in accor-
dance with the Quality of Reporting of Meta-analyses (QUOROM) statement.
The six outcome variables analysed were operating time, hospital stay, return
to normal activity, peri-operative complications, treatment failure and require-
ment for further surgery. Random effects meta-analyses were performed using
odds ratios and weighted mean differences.
Results: Twelve trials were considered suitable for the meta-analysis. A
total of 493 patients underwent OARS and 523 underwent LARS. For three
of the six outcomes the summary point estimates favoured LARS over OARS.
These included duration of hospital stay, return to normal activity and com-
plication rates. Duration of operating time was significantly longer in the
LARS group. Treatment failure rates were comparable between the two
groups. Despite this the requirement for further surgery was higher in the
LARS group.
Conclusions: Based on this meta-analysis, the authors support the use of
LARS over OARS for the treatment of proven gastro-oesophageal reflux
disease. LARS offers patients a number of benefits over OARS, with a com-
parable rate of treatment failure.
HP13
TRANSPLANTATION FOR CHOLANGIOCARCINOMA
J. L. Mccall
New Zealand Liver Transplant Unit, Auckland, New Zealand
Historically liver transplantation (LT) for cholangiocarcinoma (CCA) has
given 5 year survival of 20–30%. Recurrence rates are similar for incidental
CCA and CCA diagnosed prior to LT, and extended resections do not appear
to improve outcome. Most centres have therefore abandoned LT for CCA
because greater utility is obtained by using scarce donor organs for alternative
indications.
Two US transplant centres (Mayo-Rochester, Omaha-Nebraska) have
developed experimental LT protocols for CCA incorporating staging laparot-
omy plus neo-adjuvant chemoradiotherapy. From their recently published
data, 123 patients were enrolled and 76 (62%) underwent LT. PSC was present
in 49 (65%). Post-operative mortality was 9%, due mainly to sepsis, and there
was a high incidence of vascular complications. Of the 69 who survived LT
13 (19%) developed tumour recurrence after 1 month to 14.5 years follow-
up. Five year overall and disease free survival was 76 and 60% respectively
(Mayo). More recently, a significant proportion of the LTs were performed
using live donors.
These series show that improved results are possible but important ques-
tions remain: i) Are the results reproducible? ii) What is the best staging
method? iii) Can morbidity be reduced? iv) Are results similar for non-PSC
RACS Annual Scientific Congress, 2008
CCA? iv) Can additional patients be added to LT waiting lists without increas-
ing waiting list mortality?
These questions can only be answered by prospective clinical protocols.
The main impediment is the shortage of donor organs. LDLT is one solution
but only available to a minority of patients. CCA should be considered along-
side other controversial indications for LT.
HP14
TRAINING IN HPB SURGERY IN CHINA
W. Y. Lau
The Chinese University of Hong Kong, Shatin, Hong Kong
Not too long ago, the training of surgeons in mainland China was still the
apprenticeship system. This training system suffers from many deficiencies.
The Chinese Medical Doctors Association was founded in 2002. It is orga-
nized under the Medical Practitioners Act 1999. One of the duties of the
Chinese Medical Doctors Association is to look after postgraduate medical
education. Under the Chinese Medical Doctor Association are the Regional
Associations and the Specialty Associations (the “Colleges”).
The Chinese Association of Surgeons (The Chinese College of Surgeons)
was inaugurated on 22 September 2007 in Guangzhou. This Association or
College will be one of the 40 odd Associations/Colleges under the Chinese
Medical Doctors Association after all the associations are founded.
For training of surgeons in China, the training program is 3 years of
basic + 2 years of higher general surgery training + n years of subspecialty
training.
There have been a lot of discussions on the training components in HPB
Surgery (a subspecialty) including the proportion of liver, complex biliary and
pancreas surgery. The requirements on the amount of training in transplan-
tation, HPB laparoscopic surgery, endoscopic/interventional radiology, and
whether research should be a must, and the type of assessment on the outcome
of the HPB training have been discussed. The aim is to train a surgeon who
has acquired the necessary knowledge, skills and ability in HPB surgery.
Conclusion: HPB Surgery training in China is evolving from an appren-
ticeship system into a structural training system.
HP15
A RANDOMIZED CONTROLLED STUDY OF THE EFFICACY OF
FIBRIN GLUE IN REDUCING FLUID COLLECTIONS FOLLOWING
LIVER SURGERY
F. C. K. Chu, P. Yao and D. L. Morris
University of New South Wales, Sydney, New South Wales
Purpose: Surgical resection is the optimal treatment for liver malignan-
cies. However, abdominal fluid collection and bile leak can be great problems
during the postoperative period. We investigated the effect of fibrin glue
(Tisseel (Baxter)) sealing of the hepatic resection area, which achieved a
significant decrease of postoperative fluid collections.
Methodology: 142 patients were randomized into two group: fibrin glue
treatment and control. For the treatment group, fibrin glue was used to spray
on the raw surface, for the controls, no topical agents were used. An abdominal
drainage was placed closed to the liver surface to monitor the volume of fluid
collections. The volume of everyday drainage was recorded in standard data
sheet.
Results: The type of liver resections performed was very similar in both
groups, which including 44 major resections (more than 2 segments) and 27
minor resections in fibrin glue and 40 major resections and 31 minor resec-
tions in controls. The mean duration of drainage was 6 ± 2 days in the fibrin
glue and 8 ± 4 days in controls. Using fibrin glue, postoperative fluid amounts
were significantly lower through the postoperative period with 565–390 ml
versus 1007–1231 ml (P < 0.05). There was also significant decrease of bile
leakage in the fibrin glue group with only 1 versus 5 in the control group
(P < 0.05).
Conclusion: There was a significant decrease in post-operative fluid col-
lection and bile leakage in the fibrin glue treatment group.
Journal compilation © 2008 The Royal Australian and New Zealand College of Surgeons
A71
HP16
STRICTURES AT THE HEPATIC HILUS: A DIAGNOSTIC AND
THERAPEUTIC CHALLENGE
J. B. Koea, J. L. Mccall and G. Creamer
Auckland Hospital, Auckland, New Zealand
Introduction: Strictures at the hilus represent a diagnostic and therapeutic
challenge. A significant number of hilar strictures represent benign disease
(BS) rather than hilar cholangiocarcinoma (HC).
Methods: A prospective database of patients presenting to the HPB &
Upper Gastrointestinal Unit was established in 1998. Patients with hilar stric-
tures without a past history of cholecystectomy, sclerosing cholangitis, radi-
ation or cholangiohepatitis were analysed.
Results: All patients presented with obstructive jaundice and were inves-
tigated with tumour markers (CEA & Ca19–9), CT scan, ERCP and MRI.
Twenty three patients (19 male, median age 70 yrs) presented with HC while
16 patients (7 male, median age 63 yrs) presented with BS. Patients with HC
presented with a higher Ca19–9 than BS (2316 ± 46 versus 641 ± 38 IU/ml:
p < 0.01). HC was associated with the presence of a mass on CT scan (19 of
23 versus 2 of 17; p < 0.05) and a late enhancing stricture on MRI scan (21
of 23 versus 3 of 17; p < 0.05). All 23 patients with HC were resected with
a median survival of 23 months and microscopically clear margins in 21
patients. Of 16 patients with BS, 3 were treated with hepatectomy while 13
were managed with extrahepatic biliary excision. All patients remain alive at
a median followup of 27 months.
Conclusions: In hilar strictures raised Ca19–9 and the presence of a late
enhancing mass on MRI are strong indicators of underlying malignancy.
Aggressive surgical surgical resection results in improved survival and symp-
tom control.
HP17
ALCOHOL STRIFE, ACUTE PANCREATITIS IN ALICE SPRINGS
AND THE LESSONS LEARNT
F. Boseto, O. J. Jacob and A. O. Jacob
Alice Springs Hospital, Alice Springs, Northern Territory
Acute Pancreatitis is a potentially fatal disease with varying incidence world-
wide. The current study is a six year (2001–2006) epidemiological study,
undertaken to establish the incidence, aetiology, management issues, compli-
cations and mortality associated with acute pancreatitis in Alice Springs Hos-
pital. There were 778 episodes of acute pancreatitis with an annual incidence
of 259 per 100,000 which is the highest reported in the world. 90% of the
patients were of aboriginal background and alcohol was the dominant aetio-
logical factor. Most of the cases were mild and self-limiting; however 206
patients had severe pancreatitis of which 77 patients had necrotizing pancre-
atitis. 5 patients had undergone necrosectomy for infected pancreatic necrosis.
2 had undergone laparotomy for acute compartment syndrome of the abdo-
men. These patients did not have pancreatic necrosis, but fulminating haem-
orrhagic pancreatitis. In the all these cases the abdomen was left open. A
simple economical method of temporary abdominal closure using “fish”,
mesh, and Vacuum Assisted Closure (VAC) dressing was developed in Alice
Springs. The authors have learnt that clinical assessment of severity of
pancreatitis is superior to various scoring systems. Early aggressive fluid
resuscitation, introduction of guidelines for admitting patients to HDU/ICU,
intra-abdominal pressure monitoring for patients admitted to ICU, and
necrosectomy for infected pancreatic necrosis are measures that has kept the
mortality under 1%.
HP18
LAPAROSCOPIC CHOLEDOCHOTOMY-DISTENSION OF
COMMON BILE DUCT VIA TRANSCYSTIC INFUSION OF
SALINE MAKES CHOLEDOCHOTOMY EASIER
B. Patel, M. Donovan and N. O’rourke
Royal Brisbane and Women’s Hospital, Brisbane, Queensland
Introduction: Laparoscopic cholecystectomy and common bile duct
exploration is the gold standard for treating choledcholithiasis in the presence
of cholelithiasis. However laparoscopic exploration of common bile duct is a
technical challenge.
A72
Objectives: We aim to demonstrate that infusion of saline transcystically
makes laparoscopic choledochotomy a safe and easier procedure.
Methods and Materials: We have performed over 200 laparoscopic cho-
ledochotomies. Incising the common bile duct can lead to strictures especially
in small size ducts. A simple technique to make choledochotomy safer is to
instill saline under pressure into the common bile duct via the cystic duct.
This causes the duct to become a tight expanded cylinder thereby allowing
precise 12 o’clock site for incision. Without this manoeuvre the common bile
duct can be a flat sleeve and subject to injury due to poor definition.
Conclusion: Since this technique has been followed there has been no
injury to the common bile duct.
HP19
SURGICAL MANAGEMENT OF HEPATOCELLULAR CARCINOMA
– TRANSPLANTATION VERSUS RESECTION
L. Peng, J. W. C. Chen and R. T. A. Padbury
Flinders Medical Centre, Flinders, South Australia
Background: The incidence of Hepatocellular Carcinoma (HCC)
increased by 400% in Australia over the last 2 decades. Surgical management
with liver resection (LR) or transplantation (OLTX) remains the mainstay for
long-term survival.
The aim of this retrospective study was to audit the surgical management
of HCC at our unit.
Methods: Sixty six patients with HCC that were managed surgically
between Jan 1992 and Jan 2008 were reviewed. The medical, pathology and
radiological records of these patients were scrutinized for pre and post oper-
ative variables and analysed with respect to patient survival and recurrence.
Results: Thirty-nine patients underwent LR and 27 had OLTX. The overall
median was 37.0 (OLTX 36.8, LR 37.2) months. 68% of OLTX patients had
multiple HCCs compared with 72% of solitary HCC in LR group (p = 0.02).
LR patients had larger mean tumour size compared with OLTX group (7.5 cm
vs 2.5 cm, p < 0.0001). In OLTX group, 76% of patients were within Milan
Criteria.
The overall hospital mortality was 1.5% (n = 1). There were no in hospital
mortality for patients treated with LR compared with a single death in OLTX
group. The 1-year, 3-year and 5-year survival rates were 84%, 72% and 72%
for OLTX and 84%, 66% and 60% for LR. Recurrence rate in patients with
OLTX was lower than those treated with resection. 24% of patients treated
with resection had recurrence at the time of follow-up compared with only 1
case in the OLTX group.
Conclusions: Selected HCC patients can be managed with low in-hospital
mortality. Liver transplantation for HCC is associated with low tumour
recurrence.
HP20
ADJUVANT LIPIODOL I-131 AFTER CURATIVE RESECTION/
ABLATION OF HEPATOCELLULAR CARCINOMA
K. M. Ng, R. Niu, T. D. Yan, J. Zhao, F. C. K. Chu and D. L. Morris
UNSW Department of Surgery, St. George Hospital, Sydney, New South Wales
Purpose: A total of 329 patients with hepatocellular carcinoma have been
treated on our unit since 1990. Following the randomized controlled trial
in Hong Kong by Lau et al. (1999), patients were offered adjuvant lipiodol
I-131. The aim of this study was to determine the effectiveness of adjuvant
lipiodol I-131 post-resection and/or ablation on the overall and disease-free
survival rates.
Methods: The prospectively updated hepatocellular carcinoma database
was retrospectively analysed. A total of 34 patients were identified to have
received adjuvant lipiodol I-131 post-curative treatment with surgical resec-
tion and/or ablation since April 2000. Patient demographics, clinical, surgical,
pathology and survival data were collected and analysed.
Results: 3 patients received ablation alone, 23 resection, and 8 resec-
tion and ablation. Of the 34 treated patients, there were 2 possible cases of
treatment-related fatality (pneumonitis and liver failure).
Potential prognostic factors studied for effect on survival included age,
gender, serum AFP concentration, Child-Pugh score, cirrhosis, tumour size,
portal vein tumour thrombus, tumour rupture, and vascular and margin
involvement.
Journal compilation © 2008 The Royal Australian and New Zealand College of Surgeons
ANZ J. Surg. 2008; 78 (Suppl. 1)
The median follow-up duration was 25.3 months. The overall median sur-
vival was 58.5 months. The overall survival at 1, 2, 3 and 4 years were 87.1%,
75.4%, 64.6% and 52.9%, respectively. Median duration to recurrence was
21.2 months.
Conclusion: Administration of adjuvant lipiodol I-131 was associated
with good overall survival.
HP21
A RETROSPECTIVE ANALYSIS OF PERCUTANEOUS
TRANSHEPATIC INTERNAL-EXTERNAL BILIARY DRAINAGE
FOR MALIGNANT BILIARY OBSTRUCTION
D. A. Westwood, L. H. R. Whitaker, C. Fernando and S. J. Connor
Christchurch Hospital, Christchurch, Canterbury, New Zealand
Purpose: When percutaneous transhepatic biliary drainage (PTBD) is
required for the management of malignant biliary obstruction the local policy
favours the use of internal-external drains. Regular planned drain exchanges
are scheduled and patients have open access back into the system to minimize
complications. The aim of this study was to evaluate the success and compli-
cation rate of this method for the palliation of malignant biliary obstruction.
Methodology: The hospital records of 43 consecutive patients who under-
went PTBD for malignant biliary obstruction at a single institution between
1st February 2004 and 31st January 2006 were reviewed. Outcomes were
examined until January 2008.
Results: Overall biliary decompression was achieved in all 43 patients. In
16 patients obstruction was at the perihilar level. There was one procedure-
related death. The median post-procedure stay was five (range 1–25) days.
There were 91 routine outpatient drain exchanges performed at a median
interval of 45 (range 21–64) days. Overall, 24/43 patients encountered 80
discrete complications related to biliary drainage. Fifty-two non-scheduled
drain changes (accounting for 65% of all complications) were performed on
an outpatient basis. Fourteen patients were readmitted on a median of one
(range 1–3) occasion for a median duration of three (range 1–12) days.
Median survival was 71 (range 7–850) days.
Conclusion: PTBD can be performed with low mortality but long term
morbidity remains high despite an aggressive approach to maintaining biliary
patency. Providing patients with an open access service means the majority
of complications can be dealt with on an outpatient basis.
HP22
RADIOACTIVE MICROSPHERES FOR UNRESECTABLE
NEUROENDOCRINE LIVER METASTASES (NETLM)
J. King, D. Glenn, R. Quinn, J. Janssen, W. Liauw and D. L. Morris
St George Hospital UNSW Dept of Surgery, Sydney, New South Wales
Purpose: To prospectively assess safety and efficacy of yttrium 90 resin
microspheres in unresectable NETLM.
Methodology: Yyttrium90 micro-spheres (SIR-Spheres ®) were adminis-
tered via temporarily placed percutaneous hepatic artery catheter with one
concomitant weekly systemic infusion of 5-flurouracil to 34 patients with
inoperable NETLM. Treatment response was measured by 3 monthly CT and
Chromogranin A (CgA).
Results: 34 four patients (22 males), mean age 61 years (range 32–79)
with inoperable NETLM were treated from December 2003 to December
2005. Mean follow-up was 33.2 months (95% CI 29.9–36.7). Site of primary
NET was: 1 bronchus; 2 medullary thyroid; 15 gastro-intestinal; 8 pancreas
and 8 unknown origin. Tumours were: 1 vipoma, 1 somatostatinoma, 2 glu-
cagonoma, 3 large cell, 23 carcinoid and 2 unknown origin. Complications
post-SIRT included: abdominal pain, mild to severe; nausea, fever and leth-
argy one week to one month. Three patients developed biopsy-proven radia-
tion gastritis or ulcer and there was one early death from liver dysfunction.
55% of patients had symptomatic response. 50% of patients had radiological
liver response: 6 CR (18%) and 11 PR (32%) with median overall survival of
24.4 months (95%CI 18.4–30.4). 19 (26%) had post baseline CgA fall at one
month; 19 (41%) at 3 months; 15 (43%) at 6 months; 11 (42%) at 12 months;
8 (38%) at 24 months and 3 (46%) at 30 months.
Conclusion: An open study of 34 patients demonstrated that radioembo-
lization with radioactive SIR Spheres can achieve relatively long term
responses in some patients with unresectable neuroendocrine liver metastases.
RACS Annual Scientific Congress, 2008
HP23
UTILITY OF REPEATED ERCP IN THE MANAGEMENT OF
RECURRENT PRIMARY CHOLEDOCHOLITHIASIS
G. P. Kohn, A. S. Hassen, S. W. Banting, S. Mackay and R. J. Cade
Box Hill Hospital, Melbourne, Victoria
Purpose: The management of recurrent choledocholithiasis today remains
as challenging as in the pre-endoscopic era. Two to seven percent of affected
patients have historically required surgical intervention for the treatment of
recurrent or retained choledocholithiasis, and of these as many as 24 percent
will develop biliary complications. To avoid surgery, repeated endoscopic
management of the problem has been advocated. In this study we evaluate
our policy of repeated endoscopic management of recurrent primary bile duct
stones.
Methodology: This study examined a cohort of nine patients identified
from a prospective database with recurrent choledocholithiasis. Demographic,
clinical and investigative details were recorded and data were analysed. Com-
plications were determined from a review of the patient’s file.
Results: There were nine patients, and sixty-six procedures were per-
formed. Mean age at time of first endoscopy was 70.1 years [36–91]. Three
patients were male (33.3%). The mean number of endoscopies performed per
patient was 7.3 [3–13]. Failure to completely clear the duct occurred in 36.4%
of all endoscopies. No periprocedural complications occurred.
Conclusion: In a small group of patients with primary bile duct stones, we
have demonstrated that whilst further stone formation is the norm, repeated
ERCP is safe and surgical intervention is not required.
HP24
LIVER RESECTIONS FOR COLORECTAL CANCER METASTASIES
AT AUCKLAND HOSPITAL
G. L. Creamer, J. Mccall and J. Koea
Auckland City Hospital, Auckland, New Zealand
Introduction: Five year survivorship from colorectal cancer metastases to
the liver, untreated, approximates zero per cent. Both liver surgery and che-
motherapy have contributed to longer survivorship. At Auckland City hospital
both approaches are used in the treatment of patients with resectable colorectal
cancer metastases to the liver.
Aim: To review the experience of liver surgery at Auckland City Hospital,
for colorectal metastases.
Methods: The hepato-biliary database was utilized to identify patients
who had surgical treatment for pre-operatively identified colorectal meta-
stases, between January 1995 and December 2005.
Results: 314 patients were identified. 43 patients had non-resective surgery
(staging laparoscopy, laparotomy without proceeding or open radiofrequency
ablation). 165 liver resection patients had complete follow-up data: 10% were
alive disease free, 7% were alive with disease. Of those who had died, 29
patients had survived more than five years post initial resection.
Conclusions: In resectable patients, resection with chemotherapy results
in longer survival than might otherwise be seen.
HP25
PANCREATIC RESECTION – DEFINING THE LIMITS
D. J. Martin, M. Wente, H. Friess, R. Padbury, C. Bassi and
M. W. Buechler
University of Heidelberg, Badem-Württemberg, Germany
Introduction: Resection criteria for pancreatic cancer are influenced by
numerous factors including the accuracy and interpretation of diagnostic radi-
ology, surgical comfort level, & beliefs regarding morbidity and long-term
benefit of more borderline resections. We systematically examine the evidence
to define pragmatic evidenced based criteria that are critical in selecting
patients for appropriate management.
Methods: Data from contemporary original reports, randomized trials and
evidence based reviews of pancreatic cancer resection, including for diagnos-
tic and staging modalities were analysed. Detailed operative photographs &
imaging are used to illustrate vascular resections.
Journal compilation © 2008 The Royal Australian and New Zealand College of Surgeons
A73
Results: Over 100 relevant studies to Feb 2006 were identified & used to
critically evaluate pancreatic resection criteria. Fine slice helical CT scan with
arterial & venous contrast is the most accurate form of determining local
resectability. Complete tumour removal via enbloc major venous resection has
equivalent outcomes to standard resection in most studies & is superior
to chemoradiation. Histological depth & length of venous invasion can be
equated with CT findings & affects prognosis. Suspected venous invasion by
tumour, as indicated by pre-op imaging, of >50% vessel encasement for a
distance >1 cm is considered appropriate for centres attempting complete
tumour removal though an en-bloc venous resection. No evidence supports
resection for arterial invasion and isolated metastases but ongoing assessment
from specialized units is needed.
Conclusions: Data suggests that venous involvement, at least to some
degree, is a function of tumour location rather than an indicator of aggressive
tumour biology.
HP26
DISTAL PANCREATECTOMY: MORBIDITY AND MORTALITY
WITH A SPECIAL FOCUS ON THE METHOD OF PANCREATIC
STUMP CLOSURE
S. S. Chaloob, R. Alzubaidy, J. A. R. Williams, P. M. Dolan and
C. S. Worthley
Royal Adelaide Hospital, Adelaide, South Australia
Purpose: The purpose of this study was to define the morbidity, in partic-
ular the formation of a pancreatic fistula, and the mortality of patients after
distal pancreatectomy, with a special focus on the relationship between these
features and the method of closure of the pancreatic stump.
Methodology: Retrospective analysis of the records of all patients who
underwent distal pancreatectomy between November 1993 and August 2007
on the Hepatobiliary Pancreatic Surgery Unit of the Royal Adelaide Hospital
was performed. Clinical, technical and pathological data were correlated with
post-operative outcome. Fistula rates were compared using the Fisher Exact
Test.
Results: Twenty five patients (M : F = 14:11), median age 52 (16–77)
years, underwent distal pancreatectomy for primary pancreatic disease, extra-
pancreatic malignancy or trauma. Seventeen were elective and 8 emergency
procedures. Eighteen had benign disease and 7 malignant. Median length of
operation was 182 (range 70–360) minutes. The method of closure of the
pancreatic stump was combined (both stapled and sutured) in 16 and sutured
only in 9 patients. Prophylactic Octreotide was not used.
Four patients (16%) developed a pancreatic fistula, 2 (12.5%) being closed
with the combined method and 2 (22.2%) by suturing only. There were no
perioperative deaths.
Conclusions: Distal pancreatectomy can be performed with a low mortal-
ity and acceptable morbidity rate. Pancreatic leak and fistula remains a com-
mon complication after a distal pancreatectomy. Our series did not show one
technique of pancreatic stump closure to be statistically superior to the other
(p = 0.6016). Ways of reducing fistula rates need to be explored.
HP27
PRECOAGULATION BY RADIOFREQUENCY ABLATION IN LIVER
TRANSECTION: A SYSTEMATIC REVIEW AND META-ANALYSIS
P. Yao, X. L. Wang and D. L. Morris
University of New South Wales, Sydney, New South Wales
Purpose: Radiofrequency ablation (RFA) has been used to reduce blood
loss during liver surgery. There is however considerable controversy regarding
precoagulation by RFA in liver transection may be associated with a higher
rate of postoperative complications.
Methodology: We searched the Cochrane Central Register of Controlled
Trials, MEDLINE, EMBASE and PubMed under search term of “liver resec-
tion”, “blood loss”, “radiofrequency ablation”, “controlled controlled trial”,
“systematic review” and “meta-analysis”.
Results: A total of 37 case serials and 12 controlled studies were yielded.
In these case serials, 651 patients underwent RFA-assisted liver resection,
the average blood loss was 105.3 ml, average resection time was 81.1 min,
average hospital stay was 7.2 days, 62 (9.5%) received blood transfusion,
24 (3.7%) patients developed bile leak, 3 (0.5%) developed abscess and 3
(0.5%) showed liver failure. 12 controlled studies (3 randomized and 9 non-
A74
randomized) met the inclusive criteria. The blood loss was significantly
reduced in the treatment group (weighted mean difference = −454.25 ml; %
confidence interval (CI) = −475.83, −432.67; P < 0.00001). There were no
differences in developed morbidities between groups: bile leak (odds ratio
(OR) = 1.01; 95% CI = 0.55, 1.85; P = 0.98); abscess (OR = 2.10; 95%
CI = 0.88, 5.01; P = 0.10); liver failure (OR = 0.30; 95% CI = 0.08, 1.12;
P = 0.07).
Conclusion: Precoagulation by RFA can significantly reduce intraopera-
tive blood loss, without the increase of risk of postoperative morbidities.
HP28
POST PANCREATECTOMY HAEMORRHAGE; A SYSTEMATIC
REVIEW AND META-ANALYSIS
D. J. Martin, V. V. Bintintan, H. Friess, M. W. Buechler and
C. N. Gutt
University of Heidelberg, Baden Württemberg, Germany
Background: Haemorrhage post pancreatic resection (PPH) causes signif-
icant morbidity and mortality and poses formidable diagnostic and treatment
challenges. No conclusive review or meta-analysis has previously examined
this subject.
Method and Data Sources: A systematic search of Medline and Cochrane
electronic databases was conducted for articles related to PPH. Evaluated data
included incidence, anatomic and pathophysiological correlations, diagnosis,
treatment, and patient outcomes. Statistical analysis using the Mantel-Haen-
szel and Chi Squared methods was conducted where appropriate.
Results: 30 original reports involving over 300 cases since 1989 were
identified. The incidence of PPH ranged between 3% and 20%, delayed
haemorrhage (DH) 2.3–8.7%, with a pooled mortality rate of 31%. Early
haemorrhage occurred in the first 24 hours whilst intermediate bleeding (not
previously described) occurred from 2–7 days and was usually anastomotic.
DH occurred at a mean of 10–30 days after surgery, was usually arterial,
involving pseudo-aneurysms and often preceded by anastomotic leak (73%),
abdominal sepsis (63%) and sentinel bleeding (76%). Angiography is the
investigation of choice for DH and arterial embolization has evolved as a
reliable haemostatic method, often obviating the need for emergency surgery.
Specific dedicated surgical techniques have shown to decrease the incidence
of PPH.
Conclusion: PPH is associated with high morbidity and mortality. Defini-
tion of a new subgroup is described with evidence based recommendations
for prevention, investigation and treatment of PPH defined to streamline
management, avoiding incorrect diagnoses and delayed or inappropriate
management.
HP29
PYOGENIC LIVER ABSCESS – AN AUDIT OF 10 YEARS’
EXPERIENCE
T. C. Y. Pang, T Fung and R Smith
Department of Surgery, Royal North Shore Hospital, Sydney, New South Wales
Purpose: Pyogenic liver abscess is a potentially life-threatening condition.
The aim of this study was to audit our experience of its management over the
past decade.
Methodology: During the study period of August 1998 and June 2007, 42
patients were treated for pyogenic liver abscess at Royal North Shore Hospital,
Sydney. The patients’ medical records were examined and patient demograph-
ics, presentation, imaging, procedures, antibiotic use, and microbiology were
reviewed.
Results: There were 28 males and 14 females with a median (IQR) age of
71 (55–77) years. Presentation of disease is often non-specific, with only 23
(55%) patients febrile and 13 (31%) patients with right upper quadrant ten-
derness. Average duration of symptoms prior to presentation was 11 days.
CRP was elevated in 25/25 (100%) of cases with a mean (range) value of 281
(44–595) mg/L. White cell count was elevated only in 63%. Surgical drainage
was performed in 5/38 (13%) patients, of which 2 proceeded straight to
surgery and 3 had surgical drainage after failure of percutaneous treatment.
Image-guided percutaneous drainage was performed in a total of 32 (84%)
patients. One patient was managed on antibiotic therapy alone. The most
commonly isolated pathogens were Streptococcus milleri (27%), Klebsiella
Journal compilation © 2008 The Royal Australian and New Zealand College of Surgeons
ANZ J. Surg. 2008; 78 (Suppl. 1)
pneumoniae (21%) and Escherichia coli (12%). No pathogen was isolated in
12% of cases. Overall mortality was 2 (5.3%).
Conclusion: Patients with pyogenic liver abscesses are frequently elderly,
and presents with prolonged non-specific symptoms. The majority of pyo-
genic liver abscesses can be successfully treated with antibiotics and image-
guided percutaneous drainage, but surgery may be useful in certain cases.
HP30
EXTENDED SURGERY FOR PANCREATIC CARCINOMA
J. S. Samra
Royal North Shore Hospital, Sydney, New South Wales
Pancreatic cancer is the fourth commonest cause of cancer related death in
Australia. Its early detection and complete resection are the only factors which
can result in a long term survival for the patient. Tumours in the head of the
pancreas will often invade vascular structures that pass under the neck of the
pancreas. In addition, these tumours show increased propensity to invade the
neural tissue surrounding the superior mesenteric artery. Early local lymph
node invasion and metastasis are also the hallmarks of this disease.
Technological advances in CT and MRI imaging have resulted in a signif-
icant improvement in the preoperative assessment of these tumours. Refine-
ments in surgical technique and better postoperative care have contributed to
the dramatic reduction seen in mortality associated with pancreatic cancer
surgery. This has encouraged the surgeons to be more radical in achieving R0
resection. Terms such as extended resection, extended lymphadenectomy, en-
bloc resection and radical resection have been used to describe procedures
which entail greater volume of tissue removal. The aim of this presentation is
to clarify the role of these extended resections in the management pancreatic
cancer.
HP31
NOVEL THERAPIES FOR PANCREATIC CANCER
M. A. Fink
Austin Hospital, Melbourne, Victoria
Pancreatic cancer frequently presents at a stage where curative surgery is not
possible and therefore has a high mortality rate (exceeding 95%). Gemcitab-
ine is used as first line chemotherapy standard of care. There is some evi-
dence that giving gemcitabine using a fixed dose rate improves survival, but
at the cost of increased toxicity. Studies evaluating the addition of other
chemotherapeutic agents to gemcitabine have not demonstrated improve-
ment in response or survival rates, with the exception of the National Cancer
Research Network Upper Gastrointestinal Cancer Clinical Study Group Trial
(UK), a randomized phase III trial of capecitabine plus gemcitabine versus
gemcitabine alone in 533 patients with advanced pancreatic cancer [1]. This
showed a statistically significant, but clinically modest, benefit in the
capecitabine group (response rate 14.2% versus 7.1%, P = 0.008, median
survival 7.4 versus 6.0 months, P = 0.014, respectively) at the expense of
increased neutropoenia, thrombocytopoenia, diarrhoea and hand-foot
syndrome.
The epidermal growth factor receptor (EGFR) is essential for cell division
and tumour growth, is overexpressed in pancreatic cancer and is associated
with poor prognosis. The National Cancer Institute of Canada Clinical Trials
Group Study in patients with advanced pancreatic cancer randomized 261
patients to gemcitabine plus the EGFR tyrosine kinase inhibitor, erlotinib, and
260 patients to gemcitabine plus placebo [2]. The erlotinib group had a
statistically significant, but perhaps clinically dubious, benefit over the pla-
cebo group (response rate 8.6% versus 8.0%, progression free survival 3.75
versus 3.55 months, P = 0.003, one year survival 24% versus 17%, median
survival 6.37 versus 5.91 months, P = 0.025, respectively) at the expense of
increased rash, diarrhoea, infection, stomatitis and pneumonitis and with no
benefit in quality of life. The retail cost of the addition of erlotinib per year
of life gained was $498,379. A randomized trial of gemcitabine with or
without the EGFR monoclonal antibody, cetuximab, showed no advantage in
the addition of cetuximab.
Tumour angiogenesis, by pathways such as vascular endothelial growth
factor (VEGF), is required with increase in the size of tumours and is a
potential target of therapeutic agents. The anti-VEGF monoclonal antibody,
bevacizumab, has been studied in a randomized controlled trial (CALGB
RACS Annual Scientific Congress, 2008
80303) in combination with gemcitabine versus gemcitabine plus placebo.
This study showed no benefit in the addition of bevacizumab to gemcitabine.
A phase II study of sunitinib, which affects angiogenesis pathways by block-
ing VEGF receptors but also tumour proliferation pathways, is currently under
way.
Matrix metalloproteinases (MMPs) are overexpressed in pancreatic cancer
and theoretically enhance tumour growth, angiogenesis and metastasis. Two
MMP inhibitors, marimastat and BAY12–9566, have been studied in the
context of pancreatic cancer, with no improvement in response rate or survival
compared with gemcitabine.
Mutations in the Ras oncogene are found frequently in pancreatic cancer
and are associated with poor prognosis. Two farnesyl transferase inhibitors
that inhibit Ras overexpression, tipifarnib and ionafarnib, have been studied
in pancreatic cancer, but have not shown significant benefit over gemciatbine
alone. A study of an antisense oligonucleotide that blocks Ras mRNA expres-
sion, ISIS-2503, showed no substantial benefit over historical data using
gemcitabine alone.
Both 5FU and gemcitabine have been used as radiosensitizing agents,
with encouraging response rates, though dose modification is necessary to
minimize toxicity. A study randomizing 34 patients to weekly concurrent
gemcitabine or 5-FU with radiotherapy followed by gemcitabine demon-
strated a benefit in median survival in the gemcitabine/radiation group in
comparison to 5-FU/radiation (14.5 versus 6.7 months, respectively) [3].
Alternatives to conventional external beam radiation, including brachyther-
apy using iodine-125 seeds or palladium-103, intraoperative electrons, fast
neutron particle beam therapy and helium ions, have been trialled in small
studies with some degree of success, though often with considerable toxic-
ity. More modern techniques of external beam radiation that target the
tumour more precisely, including three-dimensional conformal radiotherapy,
intensity-modulated radiation therapy and stereotactic radiotherapy are cur-
rently under evaluation.
The rather depressing results of targeted therapy in pancreatic cancer have
stimulated the search for other pathways that can be targeted, biomarkers of
such pathways, so that therapy can be tailored to the individual patient and
the possible use of a variety of combinations of such agents.
References
1. Cunningham D, Chau I, Stocken C et al. Eur J Cancer 2005;3(Suppl):S4.
2. Moore MJ, Goldstein D, Hamm J et al. Proc ASCO 2005;23(16S):1s.
3. Li CP, Chao Y, Chi KH et al. Int J Radiat Oncol Biol Phys 2003;57:98–104.
HP32
OUTCOMES OF PALLIATIVE OESOPHAGEAL STENTING FOR
NON-OPERABLE OESOPHAGEAL CARCINOMA BY ENDOSCOPIC
AND RADIOLOGICAL TECHNIQUES – A RETROSPECTIVE
ANALYSIS
T. Kelly, M. J. Burstow, S. Panchani, I. M. Khan, D. Meek and
B. Memon
Whiston Hospital, Warrington Road, Prescot, Merseyside, United Kingdom
Purpose: To conduct a retrospective analysis comparing the efficacy and
outcomes of palliative oesophageal stenting via endoscopic or radiological
techniques for malignant dysphagia over a period of 7 years at a single
institution.
Methods: From 1999 to 2006, 124 consecutive patients who received self
expanding metal stents (SEMs) primarily for malignant dysphagia were iden-
tified using an upper GI specialist nurse clinician database. Data was obtained
from patient case-notes, endoscopy, histopathology, radiology and external
agency databases.
Results: 77 (62%) patients were male and 48 (38%) were female, the mean
age was 71 (40–97) years. The predominant presenting complaints were
dysphagia (n = 112) and weight loss (n = 62). Tumours were confined to the
distal oesophagus/gastrooesophageal junction in 45 patients (79%) and to the
mid-oesophagus in 22 patients (17.7%). Common tumour types included
adenocarcinoma in 71 patients (61.5%) and squamous carcinoma in 33 (28%).
The 7 and 30 day mortality was 6% (n = 7) and 27% (n = 34) respectively.
Equal numbers of early deaths were seen in both radiological (n = 17) and
endoscopic (n = 17) groups. Causes of early inpatient death included haemor-
rage (n = 5), aspiration pneumonia (n = 3), exhaustion (n = 2), cardiac causes
(n = 3), perforation (n = 1) and sepsis (n = 1). The mean survival time was 94
(1–640) days, with no significant difference relating to stent insertion method,
histological diagnosis or tumour location. A subgroup of patients with com-
plete dysphagia (score 4) gained a mean survival of 59 days.
Journal compilation © 2008 The Royal Australian and New Zealand College of Surgeons
A75
Conclusions: Palliative stenting for malignant dysphagia improves symp-
toms and survival but is still associated with a significant risk of morbidity
and a mortality.
HP33
A COMPARATIVE STUDY OF LIVER FUNCTION CHANGES
FOLLOWING RADIOFREQUENCY ABLATION-ASSISTED LIVER
RESECTION
P. Yao and D. L. Morris
University of New South Wales, Sydney, New South Wales
Purpose: Surgical resection is the gold standard for liver carcinomas.
Control of intraoperative blood can be a real challenge. Recently radiofre-
quency ablation (RFA) has been introduced into liver resection for precoagu-
lation. In this study, we investigated the liver function tests following the RFA-
assisted liver resection.
Methodology: Between November 2003 and November 2006, a total of
72 patients underwent liver resection in our department. This cohort study
consisted of 36 patients who had undergone RFA precoagulation followed by
ultrasonic surgical aspirator (USA) transection, 36 patients who had under-
gone USA transection as control. We used InLine RFA device and RITA 1500
generator in this study. Liver function was tested before operations and in day
1, 3, 7, 14, 28 postoperatively. The select data included: aspartate aminotrans-
ferase (AST) and alanine aminotransferase (ALT), total protein, albumin,
bilirubin, international normalized ratio (INR).
Results: The type of liver resections performed was very similar in both
groups. No mortality and massive bleeding perioperatively. The liver function
tests showed the similar pattern in both group. AST was showed significant
difference in day 1, ALT and bilirubin was showed significant difference in
day 3. Then all parameters gradually returned to normal value.
Conclusion: In this study, we demonstrated that transient changes of liver
function tests could occur after In-Line RFA assisted liver resection. However,
the transient changes of liver function tests showed no apparent clinical
implication in most patients who received resection, and returned to normal
ultimately.
HP34
LIVER TRAUMA AT A MAJOR TRAUMA CENTRE IN NEW
ZEALAND: A ONE YEAR RETROSPECTIVE STUDY
R. S. Dhillon, K. T. Kao, A. Mittal, L. Hsee and G. Christie
Dept. of Surgery/Trauma, Waikato Hospital, Hamilton, New Zealand
Purpose: The liver is the most frequently injured organ in blunt abdominal
trauma (1). This study evaluates the management and outcome of blunt and
penetrating traumatic liver trauma over one year at a major trauma centre.
Methodology: Patients with abdominal trauma admitted to Waikato Hos-
pital were identified from hospital records using ICD-10 codes S30–39 from
January 2004 to January 2005. 119 patient records were then reviewed, and
those with the diagnosis of liver trauma on CT scan or at surgery were
included for the study.
Results: Of 119 patients with abdominal trauma admitted to Waikato Hos-
pital over a one year period, 20 had liver injuries. The median Injury Severity
Score (ISS) was 17 (range 4 to 75). The diagnosis of liver injury was made
via CT scan for 18 patients. There was 1 false negative CT scan on a patient
who was found to have a small liver laceration at laparotomy.
Ten patients were managed operatively. Liver injury was the major opera-
tive diagnosis in four patients. Of these patients, one had penetrating liver
injury needing liver suturing and three had severe blunt liver injuries on CT
needing hepatic packing, ERCP and radiological embolization. Ten patients
were managed non-operatively.
Conclusion: Only 2 (10%) of the patients required the services of a spe-
cialist liver surgeon. Our operative, non operative and mortality rates are
consistent with literature and data from hepatobiliary units (2,3). We conclude
that most liver trauma can be treated at a major trauma centre with ICU and
radiological expertise but a specialist liver unit may improve outcomes on of
a proportion of severely injured patients.
A76
HP35
WHAT FOLLOW-UP IS REQUIRED IN BLUNT HEPATIC TRAUMA?
M. J. Lee, P. Evans, V. Usatoff, P. Burton and C. Atkin
Monash University, Melbourne, Victoria
Purpose: The optimal follow-up of patients with blunt hepatic trauma,
particularly the role of routine imaging is unclear. AIMS: To determine
whether routine follow up imaging alters the management of patients suffering
blunt hepatic trauma and define an evidence based follow-up protocol.
Methodology: A 6 year retrospective review was conducted on consecu-
tive cases of blunt hepatic trauma at a level 1 trauma centre, utilizing review
of the prospectively maintained trauma database, clinic notes and imaging.
Demographic data, outcome and complications were recorded. Specifically
the influence of repeated Computed Tomography and Ultrasound scans on
patient management was analysed. With each of the repeated imaging studies,
chronological correlations were made with the medical records to observe for
changes in clinical management as a result of these imaging studies.
Results: From 2001 to 2007, 386 patients were admitted with blunt hepatic
trauma. (Mean age: 38 years, Mean ISS: 33, Mean Length of Stay: 16 days)
There were 262 (68%) grade I and II, 59 (15%) grade III, 47 (12%) grade IV,
16 (4%) grade V and 2 (1%) grade VI hepatic injures. Subsequently 225
patients underwent non-operative management of blunt hepatic trauma. Rou-
tine follow-up imaging was performed in 111 patients and repeat imaging due
to a clinical indication was performed in 114 patients. Total of 4 patients had
change in clinical management due to imaging studies.
Conclusion: Repeated Computed Tomography or Ultrasound scans during
the follow-up period were shown to have minimal impact on clinical manage-
ment of patients after blunt hepatic trauma. Follow up imaging is advocated
only if it is clinically warranted.
HP36
MORBIDITY AND MORTALITY IN PANCREATIC TRAUMA
S. S. Chaloob, S. A. Plagakis, C. J. Worthley, J. A. R. Williams,
P. Dolan and D. G. Iorgulescu
Royal Adelaide Hospital, Adelaide, South Australia
Purpose: We present our experience in the management of penetrating and
blunt pancreatic injuries in a small series of a single low volume trauma
centre, focussing on factors related to morbidity and mortality. We also review
the management of pancreatic trauma in existing literature.
Methodology: Retrospective analysis of the records of all patients who
were admitted with pancreatic trauma between September 1993 and January
2005 to Royal Adelaide Hospital was performed. Clinical, radiological and
pathological data were correlated with the morbidity and mortality.
Results: There were 8 patients (5 male, 3 female, average age of 25)
admitted to Royal Adelaide Hospital between September 1993 and January
2005 with pancreatic trauma. Of these 8 patients, 6 suffered from blunt trauma
and 2 from penetrating trauma; 4 were managed operatively and the other 4
managed conservatively. The average length of hospital stay was 17 days.
Overall, only 1 patient developed a pancreatic fistula, and 1 developed a
pseudocyst. The mortality in this small series was only 1 patient.
Conclusion: Although our series is very small, it is revealing of the fact
that complications and death are related to the associated injuries. We are
reviewing the classification of pancreatic trauma and the factors precipitating
the morbidity and mortality of these patients.
HP37
COMBINATION LAPAROSCOPIC RADIOFREQUENCY ABLATION
AND PARTIAL EXCISION OF SYMPTOMATIC HEPATIC
CAVERNOUS HEMANGIOMA
J. F. Ha, H. Chandraratna and S. Rao
Royal Perth Hospital, Perth, Western Australia
Hepatic cavernous hemangioma (HCH) is the most common benign liver
tumour that are found incidentally due to their asymptomatic nature. It often
follows a benign course, and the management is usually conservative.
The decision for definitive treatment depends on the balance between pro-
Journal compilation © 2008 The Royal Australian and New Zealand College of Surgeons
ANZ J. Surg. 2008; 78 (Suppl. 1)
cedural risks, symptom severity, as well as complications associated with
hemangiomas.
Whilst there is little data in the literature regarding the use of RFA in benign
liver neoplasms, successful experience in its use in hepatic malignancies has
led to its use in HCH. The laparoscopic RFA is minimally invasive, effective,
simple, safe with low risk of complications and easily reproducible in the
experienced hands.
We present a case of successful treatment of HCH with laparoscopic RFA
and recommend it as a feasible treatment in symptomatic HCH.
HP38
DUODENAL METASTASIS FROM A UTERINE
LEIOMYOSARCOMA TREATED WITH
PANCREATICODUODENECTOMY
M. J. Lee, P. Burton, A. Murugasu, W. Brown and P. Evans
Monash University, Melbourne, Victoria
Case Introduction: Primary duodenal leiomyosarcomas are rare, as are
metastasis to this region from distant primary sarcomas. Treatment of these
metastasis with radical pancreaticoduodencectomy is difficult to justify,
although improvements in survival in selected patients can occur even when
limited extra-pancreatic disease is present. We have observed an unusual case
of a uterine leiomyosarcoma which presented initially as a symptomatic
duodenal metastasis. This was thought to be a true primary duodenal leiomy-
osarcoma but was subsequently found to be originating from the uterus.
Case Report: A 62 year old previously well female presented with a 4 day
history of melaena and lethargy. Physical examination was unremarkable. The
haemoglobin was measured at 8 g/dl. Other blood tests including liver func-
tion tests were normal. The patient continued to have intermittent melaena
and required transfusion of 6 units of packed red blood cells over the next 8
days. Gastroscopy and Computed Tomography scan revealed a polypoid mass
in the duodenum, with no evidence of local lymph node enlargement or
metastatic disease. The uterus appeared normal. Local resection was
attempted, however it was clear that the tumour was densely adherent to the
medial wall of the duodenum and the head of the pancreas. Pancreaticoduo-
dencectomy was performed and the patient had an uneventful post-operative
recovery. At follow-up six month later, a full body Positron Emission Tomo-
gram (PET) scan was performed. This showed a PET avid uterine mass. The
patient then underwent a radial hysterectomy which later confirmed this to be
a leiomyosarcoma of the uterus that was identical to the resected duodenal
lesion.
HP39
POST CHOLECYSTECTOMY BILIARY COMPLICATION:
PRESENTATION AND MANAGEMENT
R. P. S. Babra, S. S. Virk, A. Ahuja, R. S. Chinna, A. Sood and
S. S. Sidhu
Dayanand Medical College & Hospital Ludhiana India, Punjab, India
Purpose: Cholecystectomy is associated with bile duct injury, incidence
of which has doubled since the introduction of laparoscopic cholecystectomy.
This study reviews the management of bile duct injury in a tertiary care centre.
Methodology: From 2003 to 2007, Thirty seven patients (25 women) of
median age 42 years (range 25–70) were referred to this centre with bile duct
injury.
Results: Patients were transferred with a median of 30 (range 1–3650)
days after cholecystectomy. Patients with laparoscopic cholecystectomy
(40.54%) had median of 7 (range 0–425) days while patients with open
cholecystectomy (59.45%) had median of 46 (range 1–3650) days. Type of
stricture was classified according to Bismuth classification which included
Type I (7) Type II (15) Type III (3) Type IV (2) Type V (2). Management after
referral included surgical reconstruction (29 patients in which Roux-en-Y
reconstruction was done), laparotomy with drainage (4), ERCP with stent
insertion (3), stump closure (2). Two patients died, who had undergone lap-
arotomy and drainage for biliary peritonitis at our centre.
Conclusion: Bile duct injury following cholecystectomy is a complex
management problem and results in significant postoperative morbidity. Most
patients referred required reconstructive surgery and patients with complex
high injuries had a risk of long term morbidity.
RACS Annual Scientific Congress, 2008
HP40
SURVIVAL AFTER TRANSARTERIAL EMBOLIZATION FOR
SPONTANEOUS RUPTURED HEPATOCELLULAR CARCINOMA
W. H. Li, C. Y. Cheuk, C. H. Kowk and M. T. Cheung
Queen Elizabeth Hospital, Hong Kong
Objectives: To examine the survival of patients with spontaneous ruptured
hepatocellular carcinoma treated with transarterial embolization.(TAE)
Patients and Methods: Patients with the diagnosis of spontaneous rup-
tured hepatocellular carcinoma treated with transarterial embolization (TAE)
were retrospectively studied. Hospital records were reviewed and data were
collected and analysed.
Results: From 2000–2006, 62 patients who had diagnosis of ruptured
hepatocellular carcinoma were managed in our hospital. All patients were
treated with transarterial embolization (TAE), with successful rate being 91%
(57/62). Early mortality (within 30 days) was 38%. Factors associated with
early mortality were old age, low hemoglobin at presentation, elevated biliru-
bin at presentation, prolonged prothrombin time at presentation (INR > 1.3),
low albumin level at presentation and unsuccessful embolization. Low albu-
min level was the only independent risk factor for early mortality. Overall
median survival was 39 days. Surgical resections were possible in 7 patients.
Their cumulative survival was significantly longer (p = 0.002) than patient
managed with non-operative treatment after embolization.
Conclusion: Transarterial embolizaion (TAE) can achieve good hemosta-
sis and patients with low albumin level, which reflects poor liver reserve and
may predict early mortality. Staged surgical resection after embolization is
safe and produces good survival outcome.
HP41P
212 CONSECUTIVE GASTRIC AND OESOPHAGEAL RESECTIONS
FOR CANCER
D. K. Chang, A. V. Biankin and N. D. Merrett
Bankstown Hospital, Sydney, New South Wales
Purpose: Upper gastrointestinal cancers are aggressive cancers with poor
prognosis, which are endemic in some areas of the world constituting major
health burden. The best management is still greatly debated especially in the
areas of peri-operative treatments and surgical technique. Here, we present
our experience in a single-surgeon, single institution setting.
Method: A retrospective analysis of a prospectively kept database on 212
consecutive patients underwent gastric and oesophageal resection for malig-
nancy between 1994 and 2007.
Results: In the 78 gastro-oesophagectomies, there were 58 AC and 20
SCC. 71 patients had Ifor-Lewis resection and 7 had McKewon. The R0/R1/
R2 rates were 85%, 12% and 4%. The leak rate was 8% and the in-hospital
mortality and morbidity rate were 6% and 45% respectively. 19% of patients
had neoadjuvant therapy and 28% of patients had adjuvant. The 3- and 5-year
OS was 61% and 41%. The 3- and 5-year DFS was 50% and 34%. In the 134
gastrectomies, they were all for AC. 78 patients had radical total gastrectomy,
53 patients had radical subtotal and 3 patients had proximal gastrectomy. The
D0/D1+/D2 resection rates were 7%, 78% and 15% and the R0/R1/R2 rates
were 84%, 7% and 8%. The leak rate was 4% and the in-hospital mortality
and morbidity rates were 7% and 31%. 6% of patients had neoadjuvant and
35% had adjuvant therapy. The 3- and 5-year OS was 54% and 29%. The 3-
and 5-year DFS was 47% and 23%.
Conclusion: This large Australian observational study showed similar
results to international series.
HP42P
ACQUIRED TRACHEO ESOPHAGEAL FISTULA COMPLICATIONS
AND SURGICAL MANAGEMENT
S. S. Virk, R. P. S. Babra and A. Ahuja
Dayanand Medical College & Hospital Ludhiana India, Punjab, India
Purpose: Acquired tracheo esophageal fistula is an uncommon clinical
entity. Endotracheal tubes and button batteries being main causative factors.
This study reviews causative factors other than common ones, their diagnosis
and management.
Journal compilation © 2008 The Royal Australian and New Zealand College of Surgeons
A77
Methodology: All consecutive patients of acquired tracheo esophageal
fistula who underwent surgical correction were reviwed from 2003 onwards.
Their aetiology, presentation and surgical details were retrieved from records.
days.
Results: Six patients included in this study were diagnosed to have
acquired tracheo esophageal fistula. Patients presented with complaint of
cough after swallowing, increased secretions, respiratory difficulty and with
evidence of aspiration of gastric contents. Diagnostic evaluation was done by
bronchoscopy and esophagoscopy. Two patients were diagnosed to have tuber-
culosis (biopsy proven), two patients had history of ingestion of aluminium
phosphide tablets while two patients had doubtful history of corrosive inges-
tion. Presentation of all patient had median of 16 (range 7–28) days. Patients
diagnosed to have tuberculosis underwent feeding jejunostomy and were put
on antituberculardrugs. Fistula site was approached through right posterolat-
eral thoracotomy. In two patients fistula communication was small, tracheal
& esophageal rent was closed primarily after separating fistula. In another two
patients segmental resection of esophagus with end to end anastomosis was
done.
Conclusion: Tuberculosis and local irritants in form of corrosive or alu-
minium phosphide are common cause of acquired tracheo esophageal fistula
in young population. Surgical management is effective with limited morbidity
and mortality.
HP43P
COMPARATIVE OUTCOME OF LAPAROSCOPIC NISSEN AND
TOUPET FUNDOPLICATION: SYMPTOMATIC IMPROVEMENT,
PATIENT SATISFACTION AND QUALITY OF LIFE
R. W. Radajewski, E. J. Hazebroek, G. S. Smith, R. Hansen, S. Liebman
and H. Berry
Royal North Shore Hospital, Sydney, New South Wales
Background: Laparoscopic antireflux surgery is an established method of
treatment of gastro-oesophageal reflux disease (GORD). This study evaluates
the efficacy of Nissen vs Toupet fundoplication in alleviating symptoms of
GORD and compares the two techniques for the development of post-fun-
doplication symptoms and quality of life at 12 months follow up.
Methods: 94 consecutive patients presenting for laparoscopic anti-reflux
surgery underwent either laparoscopic Nissen (n = 51) from February 2002 to
February 2004, or laparoscopic Toupet fundoplication (n = 43) from March
2004 to March 2006, performed by a single surgeon (GS). Symptoms were
assessed before and after the operation. Validated quality of life (QOLRAD)
and dysphagia questionnaires were applied pre- and post-operatively.
Results: There were no conversions to open surgery, perioperative com-
plications or post-operative deaths. At 12 months, 95% of patients in the
Toupet group and 92% in the Nissen group reported an improvement in reflux
symptoms (p = 0.68). The Toupet group reported patient satisfaction levels of
98% compared to 90% in the Nissen group (p = 0.21). Post fundoplication
symptoms were similar in the Toupet group (30%) and the Nissen group
(37%) (p = 0.52). There was a tendency for a higher need for dilatations after
Nissen compared to Toupet fundoplication (12% vs 2%), but this was not
statistically significant.
Conclusion: Overall symptom improvement, quality of life and patient
satisfaction are equivalent after laparoscopic Nissen or Toupet fundoplication.
There was no difference in post-fundoplication symptoms between the two
groups, although there was a trend towards a higher dilatation requirement
after complete fundoplication.
HP44P
LAPAROSCOPIC PARAOESOPHAGEAL HERNIA REPAIR: WITH
OR WITHOUT A BOUGIE?
A. Ng, E. J. Hazebroek, D. Yong, S. Fisher, H. Berry, S. Leibman and
G. S. Smith
Royal North Shore Hospital, Sydney, New South Wales
Purpose: Laparoscopic repair of paraoesophageal hernias (POH) has been
established as a safe and effective operation. An oesophageal bougie is rou-
tinely used after narrowing of the hiatus, for calibration of the repair. However,
oesophageal perforation is a well-documented and potentially fatal complica-
tion. This study compares laparoscopic POH repair with and without a bougie
to assess changes in dysphagia scores and quality of life (QOL).
A78
Methodology: From a prospectively maintained clinical database, 28
patients underwent laparoscopic POH repair with the same type of mesh
(TiMesh) between November 2004 and June 2007. In 14 patients a bougie
was used intraoperatively (group A), and in 14 patients, no bougie was used
(group B). QOL data and dysphagia scores were assessed using validated
questionnaires, pre-operatively and 6 months postoperatively.
Results: Median age, sex, and length of hospital stay were similar in both
groups. At 6 months, a worsening in dysphagia was reported in 3 patients of
group A, and in 2 patients of group B (p = NS). Improvement of dysphagia
was similar in both groups. Postoperative dysphagia score in group A was
39.36, and 39.39 in group B (p = NS). During the 6-month follow-up period,
none of the patients in either group underwent dilatation for dysphagia. In
both groups, a significant improvement in QOL was measured with QOLRAD
at 6 months (p < 0.01).
Conclusion: Laparoscopic POH repair can be adequately performed with-
out the use of a calibration bougie.
HP45P
LAPAROSCOPIC SLEEVE GASTRECTOMY, OUR
EARLY EXPERIENCE
A. K. S. Cheng, T. J. Tan and T. Zin
Alexandra Hospital, Singapore
Introduction: Laparoscopic sleeve gastrectomy is rapidly becoming a pre-
ferred procedure for bariatric surgery, with early result as good as the other
established procedures for morbid obesity. Our institution is the first to offer
this procedure in South East Asia, Previously, all our bariatric procedures have
been laparoscopic adjustable gastric banding.
Methods: 5 patients had laparoscopic sleeve gastrectomy. The longest
follow up was 14 months. Data collected included demographics, operative
details, hospital stay, complications, etc. Weight lost outcome, resolution or
otherwise of co-morbidities were carefully documented.
Results: All the operations were completed laparoscopically. Satisfactory
weight reduction outcome and resolution of co-morbidities are presented. One
major complication was managed expectantly and resolved satisfactorily.
Technical details are presented.
HP46P
LAPAROSCOPIC TREATMENT OF TOTALLY INTRATHORACIC
GASTRIC VOLVULUS
S. Niel
CHT New Caledonia, Noumea, New Caledonia
We report with intraoperative pictures and videos the laparoscopic treatment
of an intrathoracic organoaxial gastric volvulus.
This 94 years old patient, ASA 2, has been hospitalized for thoracic pain,
vomiting and upper gastrointestinal bleeding. He was known for having a
giant paraoesophageal hernia for 20 years. The oesophagogram confirmed the
intrathoracic organoaxial gastric volvulus. PPI and gastric tube decompression
improved the patient. He was operate 3 days later after breathing preparation.
The laparoscopy was made with 5 trocars (three 10 mm and two 5 mm) and
a 30° laparoscope. The maximal intraperitoneal pressure was 12 mm Hg. The
following technique was used:
– Reduction of the stomach in the abdominal cavity
– Reduction and resection of the hernia sac
– Division of the short gastric vessels
– Reduction of the lower oesophagus in the abdominal cavity
– Posterior cruroplasty
– Tension-free strenghthening of the cruroplasty and the anterior hiatal
defect by a “in-L” Proceed mesh
– Nissen fundoplication
– Posterior fixation of the fundoplication to the crura
– No anterior gastropexy
The operative time was 190 mn and blood loss was minimal.
At day 1, the oesophagogram afforded gastric tube ablation and oral take.
There were no postoperative complications and the patient leaved the hospital
at day 6. Eighteen months after surgery, he had no clinical recurrence.
Journal compilation © 2008 The Royal Australian and New Zealand College of Surgeons
ANZ J. Surg. 2008; 78 (Suppl. 1)
HP47P
RANDOMIZED TRIAL COMPARING PANTOPRAZOLE INFUSION
AND BOLUS ON RECURRENT BLEEDING AND GASTRIC PH IN
PEPTIC ULCERS
M. Y. Kan, W. K. Hung, K. M. Li, W. L. Ying, K. T. Liu and C. M. Chan
Kwong Kwah Hospital, Hong Kong
Background: To study the optimal dosing of pantoprazole on recurrent
bleeding and gastric pH after endoscopic treatment for bleeding peptic ulcer.
Methods: After endoscopic haemostasis, patients were randomly assigned
to infusion group (pantoprazole 80 mg i.v. bolus followed by continuous
infusion of 8 mg/h for 3 days) and bolus group (pantoprazole 80 mg i.v. bolus
followed by 40 mg i.v. bolus every 12 h for 3 days). Gastric pH was monitored
for 24 hours. Rebleeding within 30 days, need for surgery, transfusion require-
ment, total hospital stay, mortality rate and gastric pH were compared. 200
patients in each groups is estimated to detect a 7% difference in rebleeding
(power of 80%). A planned interim analysis is performed when 100 cases are
recruited in each arm. The trial will be terminated when there is significant
difference detected in the endpoints.
Results: 222 patients were included, with 24 patients excluded from anal-
ysis. There were 105 patients in the infusion group and 95 patients in the bolus
group. There were no differences in rebleeding rate (2.9 vs. 2.2%, P = 1.000),
need for surgery (0% vs. 1.1%, P = 0.472), 30-day mortality (0% vs. 1.1%,
P = 0.472), transfusion requirement (2.0 vs. 1.5 units, P = 0.102) and hospital
stay (6.8 vs. 6.0 days, p = 0.208). Although there was no difference in mean
pH (6.0 vs. 5.5, P = 0.877), the median pH and the % time of pH above 4
were higher in the infusion group (6.0 vs. 5.5, P = 0.043 and 87.0 vs. 77.8%,
P = 0.035).
Conclusion: The effects of pantoprazole either as infusion or bolus in
rebleeding rate after endoscopic treatment for bleeding peptic ulcers was
equivalent. The trial will continue until the target case number is reached.
HP48P
THE DEVELOPMENT OF NEO-BARRETT’S OESOPHAGUS AFTER
OESOPHAGOGASTRECTOMY: THE INFLUENCE OF PROTON
PUMP INHIBITOR THERAPY
A. M. Fox, R. J. Cade and M. W. Hii
Box Hill Hospital, Melbourne, Victoria
Purpose: The development of Barrett’s oesophagus above the anastomosis
following oesophagogastrectomy has been reported in several studies. In this
prospective study we set out to examine the prevalence of this phenomenon
and to determine whether the use of a proton pump inhibitor (PPI) was
protective.
Methodology: Twenty postoesophagectomy patients were prospectively
assessed by upper gastrointestinal endoscopy. All resections and endoscopies
were performed by a single surgeon. Four quadrant biopsies were taken 1 cm
proximal to the oesophagogastric anastomosis and details of endoscopic
appearance, biopsies, operative pathology and PPI use were recorded.
Results: Nineteen patients underwent Ivor-Lewis oesophagogastrectomy
with PPI therapy commencing in the immediate postoperative period. One
patient had a McKeown oesophagogastrectomy and was not taking a PPI.
There were 13 men and 7 women. The average time from operation was
5.3 yrs (range 1.8–9 years). Mild erosive oesophagitis was observed in 3
patients. Barrett’s epithelium was not identified in any patient though colum-
nar epithelium without intestinal metaplasia was diagnosed in one patient in
one biopsy specimen.
Conclusion: In this study the development of Barrett’s lining above an
oesophagogastric anastomosis was not seen. From our understanding of the
pathogenesis of Barrett’s oesophagus we believe this is due to early com-
mencement of PPI therapy and the high level of compliance with it. We
therefore recommend that all patients following oesophagogastrectomy
should be on such treatment.
RACS Annual Scientific Congress, 2008
HP49P
ThE PREVALENCE OF COUGH AND OTHER RESPIRATORY
SYMPTOMS IN PATIENTS WITH GASTRO-OESOPHAGEAL
REFLUX DISEASE
P. M. R. Stewart, A. J. Ing, M. C. Ngu and K. Chan
Concord Repatriation General Hospital, Sydney, New South Wales
Purpose: The prevalence of gastro-oesophageal reflux disease (GORD) in
patients with chronic cough and bronchial asthma is well established, however
there is a paucity of data on the prevalence and nature of respiratory symptoms
in patients with GORD. We conducted a pilot study to determine the preva-
lence of respiratory symptoms and lung function abnormalities including
bronchial hyperresponsiveness (BHR), in patients with reflux oesophagitis.
Methodology: Fifteen subjects with endoscopy proven reflux oesophagitis
completed the Gastro-oesophageal Reflux Questionnaire (GORQ) and the
Leicester Cough Questionnaire (LCQ). All subjects underwent lung function
and bronchial provocation testing using Methacholine. We determined the
prevalence of cough and other respiratory symptoms, and determined the
prevalence of lung function abnormalities and BHR. Analysis was performed
to determine whether severity of oesophagitis correlated with severity of
measured respiratory abnormalities.
Results: The prevalence of cough was 47%, hoarseness 27%, heartburn
67%, acid regurgitation 87%. Lung function as a group was normal, and 13%
(2/15) of subjects had BHR. Analysis showed a significant relationship
between Los Angeles (LA) grade of oesophagitis and Forced Expiratory
Volume in one second (FEV1), but not with LCQ score.
Conclusion: This pilot study indicates that patients with reflux oesphagitis
have normal lung function with no higher prevalence of BHR than the general
population, suggesting that the high prevalence of GORD in asthma may be
due to asthma having a role in inducing GORD, rather than GORD being
important in asthma’s pathogenesis.
HP50P
TREATMENT OF OESOPHAGEAL CANCER: OUTCOMES FOR
REGIONAL AND METROPOLITAN PATIENTS TREATED IN A
SINGLE UNIT
A. Ng, E. J. Hazebroek, D. Yong, H. Berry, S. Leibman and G. S. Smith
Royal North Shore Hospital, Sydney, New South Wales
Purpose: The treatment of rural patients with oesophageal cancer often
requires travel to metropolitan centres to access surgical services. Geograph-
ical isolation from specialist centres may potentially lead to unacceptable
investigation and treatment delays.
This study aims to compare investigation and treatment outcomes in
patients undergoing oesophagectomy in a single centre.
Methods: For patients undergoing oesophagectomy in our unit, intervals
from initial diagnosis to definitive surgery (ID-DS) and commencement of
definitive treatment and oesophagectomy (ID-DT) were calculated from pro-
spectively recorded data. Comparisons were made between patients living
within Northern Sydney Central Coast Area Health Service (Group A),
patients outside the area health service but within Sydney (Group B) and
patients outside Sydney (Group C). Similar comparisons were made for oper-
ative morbidity/mortality and survival.
Results: Between January 2002 and December 2007, 81 patients under-
went oesophagectomy or definitive treatment for oesophageal cancer or high
grade dysplasia in our unit. There were 56, 4, and 21 patients in Groups A, B
and C respectively. The average ID-DS was 38, 33 and 36 days for groups A,
B and C, respectively. The average ID-DT was 32 days, 47 day and 36 days
for groups A, B and C. There were no differences between these groups for
operative morbidity, mortality or survival.
Conclusions: In this series, geographical isolation proved no barrier to
timely definitive staging or treatment in patients with oesophageal cancer or
high grade dysplasia treated in this metropolitan unit.
Journal compilation © 2008 The Royal Australian and New Zealand College of Surgeons
A79
HP51P
IS LAGB LESS EFFECTIVE IN PATIENTS FOLLOWING
PREVIOUS SURGERY?
S. E. Birks, W. A. Brown, M. Anderson and P. O’brien
Monash University, Melbourne, Victoria
Background: Laparoscopic adjustable gastric banding (LAGB) is an
effective and durable treatment for obesity. It has been suggested that alter-
native surgical treatments should be offered to patients who have had previous
bariatric surgery, or who have had a complication of LAGB requiring surgical
revision.
Methods: We have compared the results of patients having primary,
uncomplicated LAGB (‘control’: n = 1489, mean age 42.6 years, mean start
BMI 44.3 ± 7.8 kg/m2) to patients having:
1. LAGB revised following one prolapse (n = 432, age 39.7 years, mean start
BMI 44.6 ± 7.0 kg/m2)
2. LAGB revised following &#8805;2 prolapses (n = 36, age 39.3 years,
mean start BMI 45.1 ± 4.7 kg/m2)
3. LAGB following previous bariatric surgery (n = 124, age 47.1 years,
mean start BMI 42.9 ± 9.0 kg/m2)
Results were analysed using ANOVA with post-hoc analysis according to the
method of Bonferroni (SPSS v15).
Results: The starting BMI was not significantly different between any
group. Excess weight-loss (%EWL) (measured average 47 months after latest
LAGB) in the control group was 46.4 ± 26.8%. This was not significantly
different to those patients having either one LAGB revision (48.6 ± 28.3%)
or &#8805;2 LAGB revisions (52.1 ± 25%). In the group that had had a
previous alternative bariatric procedure, %EWL was significantly poorer fol-
lowing LAGB (35.7 ± 60.1%) (p < 0.01).
Conclusions: LAGB is less effective in patients with previous bariatric
surgery. This may be due to scarring at the oesophagogastric junction, dener-
vating the area and preventing signals important for satiety. Revisional surgery
appears to be as effective as primary LAGB, supporting the LAGB as a long-
term solution for the disease of obesity.
HP52P
OUTCOME OF LAPAROSCOPIC BANDING – TRENDS IN
A RURAL SETTING
S. K. Warrier, R. Warrier and D. K. Chan
La Trobe Regional Hospital, Traralgon, Victoria
Purpose: Laparoscopic banding is rapidly emerging as an important tool
in the fight against obesity, proving efficient weight loss in the morbidly obese
is possible. We aimed to study the trends in weight loss following laparoscopic
banding surgery in a rural hospital.
Methods: A retrospective analysis of 190 patients who underwent laparo-
scopic banding surgery between 2002 and 2007 was undertaken. Data was
recorded on patient’s weight at time of operation and at subsequent time
intervals of 1, 2, 3, 6, 12, 18 months and yearly thereafter.
Results: The average age was 45.8 years (mean 44). 76% of patients were
female. The mean weight prior to surgery was 118.1 kg (median 116.25 kg).
The overall mean percentage weight loss was maximal at 4 years (27.76%)
compared with 27.7%, 20.68% and 11.57% at 2 years, 1 year and 3 months
respectively. Weight loss was least within the first month with mean weight
loss of 7.86 kg and 6.56% loss. Maximal weight loss for one individual was
80.73 kg, 2 years after surgery. Only 1 patient had weight gain (4.7 kg) by 1
year.
Conclusion: This study confirms that there is almost 30% weight loss from
laparoscopic banding after 2 years. The procedure continues to play a key role
in promoting weight loss in obese individuals.
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HP53P
SALVAGE OF INFECTED LAPAROSCOPIC GASTRIC BANDS
A. Ng, E. J. Hazebroek, D. Yong, H. Berry, S. Fisher, S. Leibman,
G. S. Smith and A. Ng
Royal North Shore Hospital, Sydney, New South Wales
Purpose: Laparoscopic gastric banding (LGB) for the treatment of morbid
obesity has a favourable profile in terms of operative and peri-operative
complications. There exists however a long-term risk of specific band-related
complications including sepsis, slippage and erosion. Typically band sepsis is
treated by removal of the prosthesis and antibiotic treatment.
The aim of this study was to examine cases of band sepsis with particularly
reference to band salvage in a closely followed cohort of patients.
Methodology: Clinical, anthropometric and metabolic parameters were
collected and recorded prospectively in all patients in this series. Data on
patients identified with band sepsis was examined with particular reference to
infective organisms, clinical course and ultimate outcome.
Results: Between October 2005 and November 2007, 189 patients under-
went laparoscopic gastric banding. There were no perioperative deaths and
the perioperative complication rate was 1%. Five patients suffered band infec-
tions due to various organisms. Of these, three had their band removed (one
laparoscopically and one via laparotomy). Two patients were treated by lap-
aroscopic drainage of band abscesses and antibiotics. Both patients remain
well.
Conclusion: Results from this series demonstrate that it is possible in
selected cases of band sepsis to preserve the prosthesis and achieve adequate
weight loss.
HP54P
THE EVIDENCE-BASED GUIDE TO THE APPROPRIATE
SELECTION OF TYPE OF LAPAROSCOPIC BARIATRIC SURGERY
G. P. Kohn, D. W. Overby, S. P. Haggerty, R. D. Fanelli and
T. M. Farrell
University of North Carolina at Chapel Hill, North Carolina, United States
of America
Purpose: Obesity may well be the major disease epidemic affecting West-
ern nations in the 21st century. Conservative and medical therapies have been
demonstrated not to achieve persisting weight loss or comorbidity resolution.
Many surgical procedures have been developed to improve on this, though
there remains a marked paucity of comparative data. We have reviewed
the literature and have made best-evidence recommendations to allow selec-
tion of the type of bariatric operation most appropriate to specific patients’
requirements.
Methodology: A search of the literature was performed, using both elec-
tronic and physical resources. Inclusion required that the studies addressed at
least one of the following categories of information: surgical outcomes, guide-
lines, health care economics, or quality of life. The articles were graded as to
level of evidence and recommendations were made. A patient decision-mak-
ing algorithm was constructed.
Results: The adjustable gastric band (AGB) was seen to have the lowest
perioperative risk and the lowest rate of metabolic complications. Biliopan-
creatic diversion with duodenal switch (BPD-DS) provided the highest and
most durable long-term loss of excess body weight. All procedures improved
comorbidities, though BPD-DS and Roux-en-Y gastric bypass (RGB) pro-
vided most rapid comorbidity improvement. AGB was most reversible, and
RGB was the least likely to require re-operation. RGB provides most auton-
omy from physician attendances.
Conclusion: Laparoscopic RGB, AGB and BPD-DS have all been proved
effective. Presently, operative decisions must be driven by patient and surgeon
Journal compilation © 2008 The Royal Australian and New Zealand College of Surgeons
ANZ J. Surg. 2008; 78 (Suppl. 1)
preferences, as well as considerations regarding the relative importance placed
on various discrete outcomes.
HP55P
INFECTED PANCREATIC NECROSIS: SURGICAL CHALLENGES
AND MANAGEMENT
A. Ahuja, S. S. Virk, R. S. Babra, D. Chhina, P. K. Goyal and A. Sood
Dayanand Medical College & Hospital, Ludhiana, Punjab, India
Infected pancreatic necrosis (IPN) is a late infective complication of the acute
necrotizing pancreatitis. It is characterized by significant morbidity and mor-
tality in 20–50% of patients. Patients with a positive needle aspirate i.e. Gram
stain of necrotic material, require intervention in form of Debridement (Necro-
sectomy). Causative organism: In acute bacterial pancreatitis commonly gram
−ve, gram +ve cocci and enterococci are most commonly isolated. Patients
and methods: This study was done on 30 consecutive patients of acute severe
pancreatitis at Dayanand Medical College & Hospital, Ludhiana between Jan
2004 to Dec 2006. 27 patients were operated, 3 treated conservatively. Age,
sex, etiology, complications and mortality were calculated. Etiology: Alcohol
abuse nineteen (63%), gall stone disease six (20%), unknown five (16%). In
patients with positive fine needle aspirate of pancreatic tissue necrosectomy
was done with post operative closed lavage. In our study there were 27 males
and 3 females, median age 35, range (18–80 yrs). 70% required ICU stay and
median ICU stay was 4 (1–40 days). Commonest post operative complication
was wound infection in 21 (70%) patients, pancreatic fistula twelve (40%),
billiary fistula in two (6%), colon fistula two (6%). There was a mortality of
23%. Conclusion: (1) Aggressive approach and surveillance combined with
necrosectomy and closed lavage in IPN lead to significant fall in mortality.
(2) Organ failure and high CT score are reliable predictors of mortality.
HP56P
LAPAROSCOPIC SPLENECTOMY – A 6-YEAR SINGLE
CENTER EXPERIENCE
L. Y. Chow and W. K. Yuen
Department of Surgery, University of Hong Kong, Hong Kong
Purpose: To review all laparoscopic splenectomies performed over a 6-
year period (2001–2007) in a tertiary center.
Methodology: A consecutive series of laparoscopic splenectomies per-
formed for non-traumatic, splenic pathology at Tung Wah Hospital from years
2001 to 2007 were reviewed retrospectively.
Results: 30 laparoscopic splenectomies were performed. Operative
indications included idiopathic thrombocytopenic purpura 〈ITP〉 (n = 13),
thalassaemia (n = 4), myeloproliferative disease (n = 3), thrombotic thromb-
ocytopenic purpura (n = 2), leukaemia (n = 2), acquired haemolytic anaemia
(n = 1), lymphoma (n = 1), chronic plasmodium milariae infection (n = 1),
chronic rheumatic heart disease (n = 1) and diagnostic procedures for other-
wise unexplained splenomegaly (n = 2). Spleen size ranged from 37 to 3100 g.
Operative duration ranged from 100 to 420 minutes. Hospital stay ranged from
3 to 19 days post-operation. A mean follow-up period of 1 year showed a 77%
complete remission rate for ITP. Not a single patient required conversion to
open splenectomy. There were 2 complications to date. Both patients under-
went laparoscopic splenectomy for ITP. One required a second laparotomy
and distal pancreatectomy for bleeding from the transected pancreatic surface;
the other was an incisional hernia after continuous ambulatory peritoneal
dialysis for renal failure.
Conclusion: Laparoscopic splenectomies can be performed in a safe and
cost-effective manner for all patients. The procedure is well tolerated and has
a low complication rate. It should be considered earlier in patients with ITP
to decrease the duration and morbidity of medical treatment.